Good Faith Estimate

This is an example of the Good Faith Estimate (GFE) which will be provided prior to meeting for an initial assessment appointment. This GFE describes the range of expected costs that are likely for most new patients.

Good Faith Estimate

Tether Art Therapy and Counseling, LLC

Client Name: [First Name, Last Name]

Client DOB: [00/00/0000]

Client Guardian(s) if Applicable: [Name(s)] 

Client Address: [street, city, state, zip]

Diagnosis: Deferred  

Date of Good Faith Estimate (GFE): [date issued]  This estimate is for psychotherapy services through 12/31/2026.  

The estimate below is the range of costs that is likely for most new patients. Until I do an initial evaluation and we start to work together, I will not have a clear picture of your specific diagnosis, issues, and needs. I typically see new clients once weekly, or once every other week at the beginning of services, and then decrease the frequency of appointments over time. How frequently we meet and when we adjust that will be decided together and based on what feels comfortable for you. Depending on how treatment progresses, more or fewer sessions may be needed.

Contact: If you have questions about this estimate, please contact Patti Rabinowitz at:

phone: (443) 785-8336                                                                                   email: info@tetherarttherapy.com

mail: Tether Art Therapy and Counseling, LLC 306 W Redwood St, STE 201​, Baltimore, MD 21201

Details of the Estimate

The following is a detailed list of expected charges for psychological services scheduled for up to one year of services. The estimated costs are valid for 12 months from the date of this Good Faith Estimate, unless I send you an updated Estimate. An updated GFE will be provided yearly, upon fee updates, and upon significant change in individual need.

All amounts listed per service are the full amount due per self-pay or uninsured clientele, unless otherwise pro-rated and documented by written agreement with your clinician prior to commencing services.

Estimate for a Year

This breakdown details estimated fees for 1 initial assessment, and weekly 1 hr. appointments for:

  • 1 month (4 weeks): $170 initial assessment + $600 = $770

  • 3 months (12 weeks): $170 initial assessment + $1,800 = $1,900

  • 6 months (24 weeks): $170 initial assessment + $3,600 = $3,770

  • 9 months (36 weeks): $170 initial assessment + $5,400 = $5,570

  • 12 months (approximated for 47 weeks, accounting for holidays/vacations): $170 initial assessment + $7,050 = $7,220

This breakdown details estimated fees for 1 initial assessment, and every-other week 1 hr. appointments for:

  • 1 month (2 weeks): $170 initial assessment + $300 = $470

  • 3 months (6 weeks): $170 initial assessment + $900 = $1,070

  • 6 months (12 weeks): $170 initial assessment + $1,800 = $1,970

  • 9 months (18 weeks): $170 initial assessment + $2,700 = $2,870

  • 12 months (approximated for 24 weeks, accounting for holidays/vacations): $170 initial assessment + $3,600 = $3,770

Services Provided:

55-60 Minutes Individual Assessment (first appointment): $170 (Initial appointment, including review of paperwork and any questions you may have, presenting concerns, personal history, goals, and discussion of the process of therapy)

35-60 Minutes Psychotherapy: $150 (One follow-up appointment, between 35-60 min.)

30 Minutes Psychotherapy: $135 (One follow-up appointment, up to 30 min.)

If we agree to meet for a session longer than 60 minutes, you will be billed prorated on the hourly fee. For example, a 90-minute session (one and a half hours) would be billed at $225 ($150 hourly rate x 1.5). For other session lengths, the fee will be calculated in the same way, or we can discuss an alternate fee schedule ahead of time if needed.

Late Cancel/No Show: The full cost of the scheduled appointment. The first Late Cancel or No Show is forgiven as a professional courtesy. See the Practice Policies form for more details on late cancellations and no-shows.

Phone consult up to 15 minutes: Free

Phone consult 15-30 minutes: $40, + $20 for each additional 15 minutes

Reading and responding to e-mails up to 15 minutes per week: Free

Reading and responding to e-mails 15-30 minutes: $40, + $20 for each additional 15 minutes.

If the therapist is required to participate in legal proceedings, the following fees apply:

  • Records Review & Preparation: $250 per hour

  • Deposition or Court Appearance: $350 per hour (including travel & preparation)

  • Attorney Consultation: Billed at actual costs incurred

Rendering Service Provider: Patti Rabinowitz

NPI 1: 1801137971,  NPI 2: 1235029471,   EIN: 39-3020247

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. The estimate is based on the information known to me when I did 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. 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 the Tether Art Therapy and Counseling, LLC at the contact listed above to let them know the billed charges are at least $400 higher than the GFE. You can ask them 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 (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 GFE. 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 CMS at 1-800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059 .

This GFE is not a contract.  It does not obligate you to accept the services listed above. If you do not accept these terms, Tether Art Therapy and Counseling, LLC may be unable to provide you with services. You can choose to receive care from a different provider or facility, including those in your health plan’s network.

Keep a copy of this Good Faith Estimate (GFE) in a safe place or take pictures of it. You may need it if you are billed more than $400 than the estimate provided above.