Under Section 2799B-6 of the Public Health Service Act, healthcare providers and healthcare facilities are required to provide a good faith estimate of expected charges for items and services starting January 1, 2022, to individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing, upon request or at the time of scheduling health care items and services.

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 when the estimate was created.

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. Federal law allows you to dispute (appeal) the bill if this happens.

You can dispute the bill if you are billed for more than this Good Faith Estimate.

You may contact the health care provider or facility listed 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 four 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, you must pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care 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 + tel: (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 + tel: (800) 368-1019).

Please keep a copy of this Good Faith Estimate in a safe place or take pictures. You may need it if you are billed a higher amount.

Resilience Counseling Co.

Provider NPI: 6851117916
EIN: 99-4193649

Private Pay Services and Fees

For clients with insurance, sessions are charged at the rate set by and contracted with the insurance company, with the proceeds going towards the deductible and/or copay or co-insurance. We are always happy to provide referrals to in-network providers.

Private Pay rates are as follows for services provided through Rooted Counseling (or lower based on a sliding scale):

• 90791 – Psychiatric Diagnostic Evaluation - $200

• 90832 – Psychotherapy, 30 minutes (16-37 minutes) - $175

• 90834 – Psychotherapy, 45 minutes (38-52 minutes) - $175

• 90837 – Psychotherapy, 60 minutes (53 minutes and over) -$175

• 90846 – Family or couples psychotherapy, without the patient present - $175

• 90847 – Family or couples psychotherapy, with the patient present - $175

Other Fees

Other services such as court appearances, record requests, inpatient visits, or significant telephone calls (exceeding 15 minutes) are subject to additional fees as outlined below:

There will be a $20.00 fee for returned checks. Clients will be charged $100 for appointments not canceled 48 hours before their appointment. Sessions canceled within 3 hours of the session for any reason will be charged the cancellation/no-show fee unless otherwise discussed between counselor and client. If a client is 15 minutes or more late to a session, that session is considered a no-show, will be subject to the no-show fee, and will be rescheduled.

• Court Appearances: The fee for court appearances for Resilience Counseling Co. Counselors is $1400/day for each day the counselor must attend. The total amount is due 48 hours before the scheduled court appearance. The total amount is non-refundable regardless of whether the counselor is called to testify or the time spent in court. Failure to provide the specific fees as described constitutes a release from the requested court appearance. Travel is billed at .50/mile. Additional services related to court preparation, including all correspondence with attorneys or other service providers via phone, email, or letter, documentation review, and documentation preparation, are also billed at $140/hour, rounded to the nearest 15-minute increment. The client is ultimately responsible for the final payment of any court fees. We do not testify in custody cases. A court order or a signed release of information is required for testifying and/or records/documentation.

• Telephone Calls: Telephone calls that last over 15 minutes are subject to the private pay rate, rounded to the nearest 15-minute increment.

• Record Requests: Each record request will be subject to a $20 copying fee.

• Letter Requests: All letter/documentation preparation will be billed at $140/hour, rounded to the nearest 15-minute increment. The client is ultimately responsible for the final payment for any and all documentation requests.

The cost for services rendered is the same regardless of client diagnosis. Diagnosis is determined following the intake session. The frequency of services and length of treatment are determined collaboratively between the client and counselor based on the client’s treatment needs and the client’s agency to stop sessions or refuse treatment recommendations at any time, regardless of counselor recommendations. Some clients may find they need and decide to come to therapy longer than one year, some clients may find they need counseling services for a considerably shorter amount of time or at a much lower frequency.

The total estimated cost can be determined by multiplying the service fees by the anticipated frequency of sessions over one year (52 weeks).

• The total Good Faith Estimate for weekly sessions (1 intake session (90791) and 51 individual sessions (90837) = $9,125

• The total Good Faith Estimate for bi-weekly sessions (1 intake session (90791) and 25 individual sessions (90837) = $4,575

Estimated costs are valid for 12 months from the date of the Good Faith Estimate.

Depending on individually determined financial needs and circumstances, reduced rates may be agreed upon between the client and counselor. The total private pay cost/session will never exceed the abovementioned amounts.

For out-of-network or private pay sessions, fees are paid when services are rendered. We are happy to provide you with a billing statement you may submit for “out-of-network” insurance reimbursement and tax purposes.