Explanation of Client Services Cost Estimate
This cost estimate is being provided because you are either an uninsured person or are choosing not to use your existing insurance coverage for therapy services. By signing, you agree to make a cash payment in full at the time that services are rendered. Please be advised that this provider will not "back bill" your insurance company or provide superbills to you for retroactive reimbursement, regardless of my network status with your insurance company. The estimate below is the range of costs/costs that is likely for most clients. However, until I complete an initial evaluation and we start to work together, I may not have a clear picture of your specific diagnosis, issues, and needs. In some cases, a client's issues may be more complicated, so we may need additional sessions during the time covered by this estimate. However, depending on how the treatment progresses, fewer sessions may be needed.
This estimate is based on an annual, every two-week, session schedule.
If you have questions about this estimate, please use the contact information below.
DragonFly Counseling, LLC
D. Gonzales-Holman
5201 Johnson Drive, Ste: 305, Mission, KS 66205
Disclaimer
This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. This estimate is based on the information known to both the provider and client(s) at the time of the estimate.
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, and you will be notified immediately as to any potential estimate increase. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for $400 more (per provider) than this Good Faith Estimate (GFE}, you have the right to dispute the bill.
You may contact D. Gonzales-Holman, LSCSW at the contact listed above to let them know the billed charges are $400 higher than the Good Faith Estimate provided. You can ask to update the bill to match the GFE, 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. 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 $25.00 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price of this GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay a higher amount.
To obtain additional information, start or dispute the process about your right to a Good Faith Estimate, go to https://cms.gov/nosurprises or call CMS at 1-800-985-3059.
Contact us to learn more.
