Provider Name: OCD & Anxiety Program of Southern California

Address: 3205 Ocean Park Blvd, Suite 250, Santa Monica, CA 90405

NPI: 1295278422

TAX ID: 81-4445394

Patient Name

Patient Date of Birth

Patient Address:

Patient Phone#:                                                              Patient Email:

Patient Diagnosis (if known/applicable):  R69-illness unspecified

Services Requested:

Date of Initial Session (if applicable):

List of Services and Associated Fees including applicable CPT codes:

90791 Diagnostic Evaluation Postdoctoral Fellow: $265

90791 Diagnostic Evaluation Licensed Clinician: $375

90791 Diagnostic Evaluation Senior Licensed Clinician: $450

90834 Psychotherapy 45 minutes -Postdoctoral Fellow: $175

For 12 months 1x weekly = $9,100

90834 Psychotherapy 45 minutes- Licensed Clinician: $250

For 12 months 1x weekly = $13,000

90834 Psychotherapy 45 minutes- Senior Licensed Clinician: $325

For 12 months 1x weekly = $16,900

S9480 Intensive Outpatient Services- $750

IOP Services for 4 weeks at 3 days per week = $9,000

IOP Services for 4 weeks at 5 days per week =  $15,000

IOP Services for 12 weeks at 5 days per week= $45,000

Estimated Cost:  You may calculate your Good Faith Estimat

For therapy we can’t necessarily provide an estimate of how long it takes since each individual is so different in their severity of symptoms, symptom presentation, level of motivation etc.  The frequency with which clients are seen, and the duration of time in which they are seen, is dependent on client need.  We are presenting the Good Faith Estimate as the cost of treatment for Psychotherapy for 12 months 1x weekly as $16,900.  You can adjust based on the information above.

I acknowledge that I have received my Good Faith Estimate and reviewed it with my clinician. I acknowledge that I am not obligated to obtain any of the listed services from this provider.

 Patient Signature:                                                                Date: 

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 us when the OCD & Anxiety Program 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 more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the OCD & Anxiety Program of Southern California at the contact listed above 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.

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 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 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 Good Faith Estimate is not a contract. It does not obligate you to accept the services listed above.

Keep a copy of this Good Faith Estimate 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.