Good Faith Estimate

Good Faith Estimate for Health Care and Services

Use when patients decline to use insurance.

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Date

Name(Required)

Prefix First Middle Last Suffix

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Enter Email Confirm Email

Responsible Party (if not Patient)

Preferred Contact Preference for written communication.(Required)

Postal Mail

Fax

Do you have health insurance of any kind?(Required)

Yes

If no insurance(Required)

I understand

If you do not have health insurance, please initial that you understand you are directly responsible for all fees for services provided to you.

Which insurance?(Required)

Name of Insurance company / Insurance Plan

Will you use the out-of-network insurance?(Required)

I will use my health insurance out-of-network benefits. I acknowledge that I will be responsible for paying all fees to this practice at the time of service or upon receipt of invoice and for submitting a superbill directly to my insurance company for my out-of-network benefits.

I decline to use my health insurance out-of-network benefits and will pay in full for all services at the time of service or upon receipt of invoice.

Unlike some medical services, Dr. Turnbull often cannot form an estimate of what services you will need and what they will cost until he has evaluated you. Even then, the extent of the services you will need will be influenced by many factors. Dr. Turnbull will review your treatment plan and services needs with you throughout your treatment, some of which may not be reflected in this estimate.

This good faith estimate is based on the information available at this time and actual items, services, or charges may differ from this good faith estimate as treatment progresses. Please note that these fees are the same for both in-office services and for telehealth services.

Good Faith Estimate of Costs

Together throughout treatment we will discuss how many sessions and the types of services that will be of the most benefit to you based on your diagnosis, your presenting concerns, and other relevant information that presents as we continue treatment together.

This estimate is for services provided in the coming year. The estimate may be updated whenever appropriate. You will receive a new estimate one year from now if you are continuing in therapy, unless there are no rate changes, in which case the same rates will apply going forward. You are welcome to ask questions about your services, their costs and this estimate.

You understand that this is not a contract. You also understand that if you have insurance, by signing this document it indicates that you have decided not to utilize that insurance.

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.

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  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 800-985-3059.

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 a higher amount.

Consent(Required)

I agree to the Good Faith Estimate

Good Faith Estimate of Costs

Based on the information you have provided to date, my best estimate is I will be providing service with code 90791 for the first one or two sessions (60 minutes or less), and subsequent sessions with code 90847 (60 minutes or less). All sessions are charged at the rate of $165.00.

Together throughout treatment we will discuss how many sessions and the types of services that will be of the most benefit to you based on your diagnosis, your presenting concerns, and other relevant information that presents as we continue treatment together.

This estimate is for services provided in the coming year. The estimate may be updated whenever appropriate. You will receive a new estimate one year from now if you are continuing in therapy, unless there are no rate changes, in which case the same rates will apply going forward. You are welcome to ask questions about your services, their costs and this estimate.

You understand that this is not a contract. You also understand that if you have insurance, by signing this document it indicates that you have decided not to utilize that insurance.

J. Gregory Turnbull, Psy.D., J.D.

Psychologist in private practice in Kailua, Hawaii

Good Faith Estimate

Good Faith Estimate for Health Care and Services

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