Patient Name: [Patient Name]

Date of Birth: [DOB]

Date of Estimate: [Date]

Practitioner: Aimee Yeager, LPCC-S

Business Name: Aimee Yeager, LPCC-S, LLC DBA As You Are Counseling

Tax ID (TIN):‍ 41-5371050 ‍ NPI Number: 1306364583

Address: 35 E 7th St, Suite 713  Cincinnati, OH 45202 Phone: 513-713-0083

The No Surprises Billing Act is a federal law that requires medical providers to provide a clear, plain-language notice explaining when out-of-network care might result in surprise billing and must obtain the patient's consent before billing them for out-of-network services in non-emergency situations. 

Summary of Estimated Services

This Good Faith Estimate provides an overview of expected charges for out-of-network mental health services. These estimates are based on information available at the time the estimate was created and do not include any unknown or unexpected costs that may arise during treatment. Upon request, we will provide a superbill detailing services rendered, which you may submit to your insurance for potential reimbursement. 

Service Codes and Fees

Diagnostic Assessment (60-Min) -90791                $125

45-Min Psychotherapy -90834                    $100

60-Min Psychotherapy-90837                              $125

90-Min Psychotherapy -90837+90785                                             $175

Extended EMDR Psychotherapy (3 hrs)-90837+90785 $375

Extended EMDR Psychotherapy (4 hrs) --90837+90785 $500

Group Psychotherapy -90853                          $30

Parent 45-Min Collateral Psychotherapy (for caregivers of minor clients) -90846        $90

Estimated Total Cost

The total cost of your treatment will depend on the frequency and duration of sessions we mutually agree upon. For example:

• If you attend 10 60-min therapy appointments, you can expect to pay $1,250 in out-of-pocket costs.

• If you attend 20 45-min therapy appointments, you can expect to pay $2,000 in out-of-pocket costs.

You are not obligated to attend any number of sessions based on this Good Faith Estimate. You may require fewer sessions than estimated, and you may choose to attend more sessions if progress is still being made. You can always discuss the length of treatment; progress in treatment; and plans to end treatment with your therapist at any point.

It is additionally important to understand that you are not required to seek mental health services at Aimee Yeager, LPCC-S, LLC DBA As You Are Counseling. It may be more cost effective to work with an in-network provider. If you have insurance and you are interested in working with an in-network provider at any time and for any reason, Aimee Yeager, LPCC-S, LLC DBA As You Are Counseling will do our best to help facilitate that referral.

Important Disclaimers

Your Right to Dispute: You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. If you receive a bill that is at least $400 more than this estimate, you can dispute the bill. You may contact the provider listed above to negotiate the bill or start a dispute resolution process with the U.S. Department of Health and Human Services (HHS).

Not a Contract: This estimate is not a contract and does not require you to obtain services from As You Are Counseling. You may choose to end treatment at any time or seek services from an in-network provider to reduce your out-of-pocket costs.

Estimate Limitations: This estimate does not include fees for missed, cancelled, or rescheduled appointments. Per practice policy, late cancellations or "no-shows" will be charged the full session fee. Any additional services not listed here must be agreed upon in writing.

Dispute Resolution Process

If you choose to use the formal dispute process, you must start the 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 pay the price on this Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visitwww.cms.gov/nosurprises or call HHS at (800) 368-1019.