NO SURPRISES ACT &

GOOD FAITH ESTIMATE

No Surprises Act

In compliance with the No Surprises Act that went into effect January 1, 2022, you have certain rights and protections against “surprise billing." This Act requires that we inform you of your federally protected right to receive a notification when services are rendered by a therapist who is out-of-network with your insurance provider (i.e. a non-participating provider). In addition, you have the right to receive a Good Faith Estimate explaining the cost of any non-emergency healthcare services, including psychotherapy.

Good Faith Estimate (GFE)

Provider Information

Name: Rachel Baker LICSW, SUDP, MAC

Facility: RB Counseling

Location: 222 W. Mission Ave - Ste 232, Spokane, WA 99201

Phone: (509) 402-1569

Email: rachel@rbcounseling.com

TIN: 45-2523580 NPI: 1932428414

Primary Services & Expected Charges

90791 Psychiatric Evaluation: $175

90834 Psychotherapy 45-min (standard session): $175

90837 Psychotherapy 55-min: $190

Late Canceled/Rescheduled (less thank 24hr notice): $80

No-Show Session: full session fee ($175)

Note: Fees are based upon individual session length. There is NOT a charge difference based upon diagnosis(es).

The fee schedule is evaluated annually, at a minimum. You will be given a minimum of 30 days’ notice and presented with a new Good Faith Estimate (GFE) when fees increase.

Additional services may be recommended. This estimate of your costs is only an estimate, and your actual charges may differ. You have the right to initiate the patient–provider dispute resolution process if the charges you are actual billed substantially exceed the expected charges in this estimate. This estimate of costs is not a contract and does not obligate you to obtain clinical services from us. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

Expected Scope of Recurring Services

Length, frequency and number of sessions is dependent upon your condition and is a collaborative decision made by both you and your provider. Most clients will attend one 45-minute psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs.

As noted above, the fee for a standard 45-minute psychotherapy visit (in-person or virtually) is $175. Your total estimated fees will be the number of sessions you attend, multiplied by $175 (for standard 45-minute sessions). For example, if you attend one session per week, your estimated charge would be $700 for four visits provided over the course of one month.

Note: Fees are based upon individual session length. There is NOT a charge difference based upon diagnosis(es).

Please note (a.k.a. Disclaimer):

  • This is an estimate of costs. It is not a contract and does not obligate you to obtain clinical services from RBCounseling.

  • This Good Faith Estimate (GFE) shows the costs of items and services that are reasonable expected for your health care needs for an item or service. The estimate is based on information known at the time of the estimate was created.

  • The GFE 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 by at least $400, 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 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 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.

  • For questions or more information about your right to a Good Faith Estimate (GFE) or the dispute process, please visit www.cms.gov/nosurprises.