ANDERSON COUNSELING AND WELLNESS, PLLC Good Faith Estimate for Health Care Items and Services

Effective January 1, 2022, a ruling went into effect called the “No Surprise Act” which requires practitioners to provide a “Good Faith Estimate” about out-of -network and self pay based care. The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your healthcare needs for items or services, a diagnosis, and a reason for therapy. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. If changes from the initial Good Faith Estimate are needed to provide appropriate treatment, it will be discussed at that time and a new Good Faith Estimate created and reviewed. If that does not occur and you are charged more, without an updated Good Faith Estimate, under federal law you may then dispute ( appeal) the bill.

Primary Service or Item Requested/Scheduled:

• Individual

• Family

• Couples

Disclaimer: The No Surprise Act requires a diagnosis for services, however due to the nature of therapy sessions a diagnosis before 1-2 Intake sessions is not possible or ethical. The diagnosis will be discussed after appropriate intake sessions have occurred and it does not impact the fees associated with CPT codes listed in this estimate. If you are an existing client as of 1/1/2022, and have a diagnosis on file, it will soon need to be used here as required by this law. It is also within your rights to decline a diagnosis per state and federal guidelines.

Patient Primary Diagnosis & Diagnosis Code / Patient Secondary Diagnosis & Diagnosis Code:  Common Dx Codes used are: Adjustment disorder (F43.20, F43.23, F43.21, F43.25); Generalized Anxiety disorder (F41.1); ADHD Combined Type (F90.2); other

Anderson Counseling and Wellness, PLLC Estimate:

The following is a detailed list of expected charges for Therapy Sessions beginning. . As these services are ongoing and recurring in nature, the estimated costs are relevant for 1 year from the date of the Good Faith Estimate.  We recognize that every client's therapy journey is unique. How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including, but not limited to:

❖ Your schedule and life circumstances❖ Therapist availability❖ Ongoing life challenges❖ The nature of your specific goals❖ Personal finances

You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and /or a new “Good Faith Estimate'' will be issued should your frequency or needs change.

Kerri Anderson, MA, LMFT

15 Old Park Lane Rd Suite 200

New Milford, CT 06776
860-946-3681
National Provider Identifier: 1588938831
Group National Provider Identifier: 1740783513
In Network with: Aetna, Optum, and Husky

Haley Mozonski, LPC

15 Old Park Lane Rd Suite 200

New Milford, CT 06776

860-946-3681

National Provider Identifier: 1003400854
Group National Provider Identifier: 1740783513
In Network with: Aetna, Optum, and Husky

Details of Services and Items for ACW with

• 90791 Intake session in person or via Telehealth from Litchfield County CT with Kerri Anderson, MA, LMFT or Haley Mozonski,, LPC $300

• 90837: 60 minute individual session in person or via Telehealth from Litchfield County CT, with Kerri Anderson, MA, LMFTor Haley Mozonski,, LPC $250

• 90834: 45 minute individual session in person or via Telehealth from Litchfield County CT, with Kerri Anderson, MA, LMFT or Haley Mozonski,, LPC $200

• 90846/7: 60 minute family session in person or via Telehealth from Litchfield County CT, with Kerri Anderson, MA, LMFT or Haley Mozonski,, LPC $200

Other potential fees for Kerri Anderson, MA, LMFT/ Haley Mozonski, LPC

• Late cancellation/ no show fee: $100 each occurrence

• Court appearance fee: $2,000 a day ( 10 hours at hourly rate of $200)

• Collaborative meeting with other client providers that extends over 15 minutes: $150 per hour

Total potential services for the next 6 months and estimated cost for all services and items based on agreed amount due to not accepting client's insurance: $

1 session 90791 @

1 session per week X 24 weekly sessions over 12  months @

Most clients benefit from weekly or biweekly sessions and as progress is made clients may choose to meet less frequently. This estimate is based on meeting weekly for the next 6 months, as a baseline estimate of care and is in no way dictating how treatment progresses for all clients. To be in accordance with this law, an estimate based on most likely scenarios is required and can be adjusted as the therapeutic relationship is developed.

Disclaimer

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.

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.

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 4 months) of the date on the original bill.