Good Faith Estimate Speech Therapy

Good Faith Estimate for Health Care Items and Services

Form to be completed for those who are uninsured or electing not to use insurance.
The following is a detailed list of expected charges for the listed services, scheduled for the listed dates. You may need more than one treatment. We are unable to anticipate the length of care as all people progress at different rates. This estimate is accurate within +/- $400 of the actual cost of the care for one visit. The provider may recommend additional items or services as part of the treatment that are not reflected in the estimate. These would need to be scheduled separately. The information provided in the Good Faith Estimate is only an estimate, as actual items, services, or charges may differ. The client has the right to engage in a dispute resolution process if the actual costs of services significantly exceed those listed in the Good Faith Estimate. The Good Faith Estimate does not obligate or require the client to obtain any of the listed services from the provider. The estimated costs are valid for 12 months from the date of the Good Faith Estimate.
Child's Name *

First Name Last Name
Child's Date of Birth *

Month Day Year
Date
Parent Name *

First Name Last Name
Address
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Items or Services Requested *
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Stuttering/Fluency Evaluation Includes consultation with parent and file review, 30-45 minutes of direct contact, approximately 1-1.5 hours of analysis and interpretation and includes a thorough report
$ 260.00

Articulation/Phonology Evaluation Includes consultation with parent and file review, 30-45 minutes of direct contact,approximately 1-1.5 hours of analysis and interpretation and includes a thorough report.
$ 260.00

Comprehensive Speech-Language Evaluation Includes consultation with parent and file review, 1-2 hours of direct contact, possibly over 2 sessions, followed by approximately 1-2 hours of analysis and interpretation and includes a thorough report. (Select if concerns are not limited to speech sound production and/or stuttering)
$ 360.00

Individual Speech Therapy Session Inclusive of preparation time, resources/materials made for your child’s therapy, record keeping, home programming, quarterly progress reports, and consultation with other professionals to coordinate therapy.
$ 120.00 Quantity

Total

$ 0.00
The above is your total estimated cost for services selected.

Diagnosis: unknown until after initial treatment
Date of Good Faith Estimate (today) *

Month Day Year
Date
Provider Consulted With *
Please enter the email where you would like to receive a password-protected copy of this form. Please note down the password for your records: 1TPLspeech! *
example@example.com
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Good Faith Estimate for Health Care Items and Services