GOOD FAITH ESTIMATE

Provider Name: Eric Stroshine, Massachusetts License # 124120, Provider Mailing Address: 100 Independence Drive, Suite 7, Hyannis, MA 02601, Provider Phone #: (508) 470-8605, Provider Tax ID# 87-343-4162, Provider Personal NPI # 194-285-3841, Provider Business NPI # 189-144-7355.

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges. You have the right to receive a Good Faith Estimate for the total expected cost of any nonemergency items or services.

Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059.

The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you. The fee for a 45-60-minute psychotherapy visit (in-person or via telehealth), is $125.00. Most clients will attend one 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. Based upon a fee of $125.00 per visit, if you attend one psychotherapy visit per week, your estimated charge would be $500.00 for four visits, provided over the course of one month; $1,000.00 for eight visits over two months; or $1500.00 for 12 visits over three months. If you attend therapy for a longer period, your total estimated charges will increase according to the number of visits and length of treatment. There may be additional items or services I may recommend as part of your care, that must be scheduled or requested separately, and are not reflected in this good faith estimate. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $500.00 or more beyond the estimated charges). You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.

I have read and agreed to the terms stated below.  Client’s Name (Printed)___________________________________

Signature_____________________________________Date_______________________________________________

Clinician’s Name (Printed)____________________________Signature_______________________Date____________