Good Faith Estimate

Under Section 2799B-6 of the Public Health Serice Act, health care providers need to give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items and services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. Make sure your health care provider gives you a Good Faith Estimate in writing at least one (1) business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you begin treatment.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

This Good Faith Estimate is not a contract and does not require the uninsured or self-pay individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate herein. It's intention is to inform you of all fees for service and outline potential schedules and costs on a yearly basis; however, scheduling and treatment frequency is ultimately up to you.

The clinicians at Austin Women's Counseling are not in network with any insurance companies. Should you wish to utilize in-network benefits for mental health services, please contact your insurer for a list of in-network providers.

The following is a detailed list of expected charges. The estimated costs are valid for 12 months or until December 31, 2023 from the date of the Good Faith Estimate.

Provider Estimates - *Maximum does not include late cancelation/no show fees or non-therapeutic charges e.g. documentation fees, banking fees, court/litigation fees, or other financial arrangements based on a case-by-case basis. See the informed consent policy as well as the information below for complete details regarding this fee schedule. Please note that all sessions are scheduled as either 30 or 50 minutes with the exception of intake.  The following descriptions are based on CPT coding.

Psychotherapy traditional fees:

00000 ~ Initial Consultation (Psychiatric Diagnostic Evaluation) 15 minutes - $0.00

90791 ~ Intake Session - Individual 75 minutes - $175.00

90791 ~ Intake Session - Couple/Family 75 minutes - $175.00

90832 ~ Individual Psychotherapy, 30 - 44 minutes - $75.00

90834 ~ Individual Psychotherapy, 45 - 52 minutes - $145.00

90837 ~ Individual Psychotherapy, 53 - 60 minutes - $145.00

90846 ~ Family Psychotherapy, conjoint psychotherapy w/o patient present 50 minutes -$145.00

90847 ~ Family Psychotherapy, conjoint psychotherapy w/ patient present 50 minutes -$145.00

  

Psychotherapy fees with student therapist:

00000 ~ Initial Consultation (Psychiatric Diagnostic Evaluation) 15 minutes - $0.00

90791 ~ Intake Session - Individual 75 minutes - $50.00

90791 ~ Intake Session - Couple/Family 75 minutes - $50.00

90832 ~ Individual Psychotherapy, 30 - 44 minutes - $25.00

90834 ~ Individual Psychotherapy, 45 - 52 minutes - $40.00

90837 ~ Individual Psychotherapy, 53 - 60 minutes - $40.00

90846 ~ Family Psychotherapy, conjoint psychotherapy w/o patient present 50 minutes -$40.00

90847 ~ Family Psychotherapy, conjoint psychotherapy w/ patient present 50 minutes -$40.00

Additional Services:

Couples sessions, 80 minutes - $60

Non-Therapeutic/Other Fees:

Charge Backs - $30.00
Non-sufficient funds (NSF) - $30.00
Documentation Fee - $30.00

Sessions canceled with less than 24 business hours notice that are not an agreed upon emergency and unable to be rescheduled within the same week will be charged half of the agreed upon fee for that scheduled session for the first occurance and then full fee thereafter. 

Late arrivals or early terminations will be charged the full amount for the agreed upon time for that scheduled session.

Court/Litigation:
Retainer for court services due IN ADVANCE - $1500.00
Communications (phone, text/SMS, email, written letters, etc.) - $200.00 per hour
Preparation (including submission of records, cancellation of clients, etc.) - $200.00 per hour
In-court appearance (including wait time/standby) - $1500.00 per day for any length of time
Travel & Mileage - $250.00 per hour plus $0.56 per mile
Court filing - $100.00 plus associated fees
Express service (Less than 72 business hours) - $250.00
Reset fee (Less than 72 business hours) - $500.00

Everyone comes to therapy with different concerns and experiences that are unique to them, making an estimate about the costs of psychotherapy challenging. Response to treatment can be affected by different psychosocial factors and can potentially lengthen the process of therapy. The length of time and frequency you will need to be in therapy is based on your therapeutic goals, client and therapist schedules, client overall wants and needs, and any psychosocial/financial barriers that may arise. 

Some people choose to seek therapy more long term and consider it an important aspect of their lives. Others choose to focus on one issue and then discontinue therapy when that issue has resolved. There is the potential throughout the course of treatment that it might be recommended to meet with more frequency (for example, moving from biweekly appointments to weekly appointments) and may move back to biweekly appointments once the issue of concern is stabilized. If treatment switches from biweekly to weekly sessions, the estimate of what services will cost in a 12 month period will change, reflective of however many weeks are left in the year multiplied by the fee per session.

Providers are unable to provide an estimate on the length of treatment or a specific diagnosis to a client that they have never met. The diagnosis provided below is a starting point and liable to change depending on the specific presenting issues. With this being said, communication is key to any healthy relationship. Should a financial hardship occur, you are encouraged to discuss your situation with your provider to determine the best resolution as it pertains to your continuity of care and the therapeutic relationship.

Should more time be required to meet your therapeutic goals, the therapists at Austin Women's Counseling will discuss your options with you at which time a new Good Faith Estimate may be created, your therapeutic services will end, or you are referred to another provider. 

You are allowed to terminate your therapy at any time. Below you will see a list of totals based on weekly, bi-weekly, and monthly totals equating in an estimate for one calendar year.  These totals DO NOT account for no show/late cancelation fees, bank charges, crisis sessions, non-therapeutic charges e.g. documentation fees, banking fees, court/litigation fees, or other financial arrangements based on a case-by-case basis. You are encouraged to carefully read the Informed Consent policy, and view the website fee listing for any additional info regarding the fee schedule not otherwise listed here.  

 

Lastly, this estimate is not a guarantee of services. Ethical guidelines require providers not to practice outside out scope of experience/expertise, and at times it is not known until after a service has been provided whether or not this is an issue between provider and client. Referrals out after the first meeting may occur in some circumstances. Please do not hesitate to ask for clarifying information.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created and is not intended for use as a receipt for out of network billing receipts.  Should you require a superbill, please contact your provider. Additionally, the diagnosis provided in this estimate is likely to evolve.  Should you have questions, please contact your provider.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. Again, that said communication is key and you are encouraged to contact your provider with any concerns regarding billing first to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the healthcare provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 368-1019. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

As stated above, please review the Informed Consent and website for complete details regarding Austin Women's Counseling's fee schedule not otherwise outlined in this agreement. *Maximum DOES NOT account for no show/late cancelation fees, bank charges, crisis sessions, non-therapeutic charges e.g. documentation fees, banking fees, court/litigation fees, or other financial arrangements based on a case-by-case basis.

Provider/Facility Type:

Outpatient Psychotherapy

 

Mailing Address:

1106 Clayton Lane, Ste. 522W

Austin, TX  78723

 

Main Phone: 512.981.5638

 

Email: brianne@austinwomenscounseling.com

 

National Provider Identifier (NPI) for Brianne Blevins: 1962804385 

Taxpayer Identification Number (TIN): 471722398

Service/Item: Psychotherapy Sessions

Address where service/item will be provided: N/A. Services provided via Telehealth

Diagnosis Code: Z65.9 (Problem related to unspecified psychosocial circumstances)

 Quantity (MONTHLY):

 

Psychotherapy traditional fees:

1 intake session @$175.00 = $175.00 

12 - 30-44 minute sessions (1 session x 1 month x 12 months) @ $75.00 = $900.00 (PENDING NEED)

12 - 45-53 minutes sessions (1 session X 1 month X 12 months) @ $145.00 = $1,740.00

 

Psychotherapy fees with student therapist:

1 intake session @$50.00 = $50.00 

12 - 30-44 minute sessions (1 session x 1 month x 12 months) @ $25.00 = $300.00(PENDING NEED) 

12 - 45-53 minutes sessions (1 session X 1 month X 12 months) @ $40.00 = $480.00

 

Quantity (Bi-Weekly):

 

Psychotherapy traditional fees:

1 intake session @$175.00 = $175.00 

12 - 30-44 minute sessions (1 session x 26 weeks) @ $75.00 = $1,950.00(PENDING NEED)

12 - 45-53 minutes sessions (1 session x 26 weeks) @ $145.00 = $3,770.00

 

Psychotherapy fees with student therapist:

1 intake session @$50.00 = $50.00 

12 - 30-44 minute sessions (1 session x 26 weeks) @ $25.00 = $650.00(PENDING NEED)

12 - 45-53 minutes sessions (1 session x 26 weeks) @ $40.00 = $1,040.00

 

Quantity (Weekly):

 

Psychotherapy traditional fees:

1 intake session @$175.00 = $175.00 

12 - 30-44 minute sessions (1 session x 52 weeks) @ $75.00 = $3,900.00 (PENDING NEED)

12 - 45-53 minutes sessions (1 session x 52 weeks) @ $145.00 = $7,540.00

 

Psychotherapy fees with student therapist:

1 intake session @$50.00 = $50.00 

12 - 30-44 minute sessions (1 session x 52 weeks) @ $25.00 = $1,300.00 (PENDING NEED)

12 - 45-53 minutes sessions (1 session x 52 weeks) @ $40.00 = $2,080.00

*Maximum does not include late cancelation/no show fees, crisis sessions, non- therapeutic charges e.g. documentation fees, banking fees, court/litigation fees, or other financial arrangements based on a case-by-case.