Good Faith Estimate

(For Private Pay clients only, who are not seeking reimbursement from their insurance provider.)

Notice: You have the right to receive a “good faith estimate” explaining how much your medical care will cost. This will be provided to you directly by your clinician.

Starting January 1, 2022, the “No Surprises Act” requires healthcare providers to offer a “Good Faith Estimate” (GFE) to uninsured individuals or those paying directly for services. The GFE outlines anticipated costs for specific treatments and is based on available information at the time. It does not include unexpected expenses, such as charges for missed appointments or complications, which may require a new GFE. If your total bill exceeds $400 per year and there was no prior discussion or updated GFE, federal law allows you to contest the bill.

Under Section 2799B-6 of the Public Health Service Act (PHSA), Health care providers (counselors) and health care facilities must inform patients who are either not enrolled in a plan or coverage, not part of a Federal health care program, or not looking to file a claim with their plan or coverage, both verbally and in writing, about their right to request a Good Faith Estimate (GFE) of anticipated charges, either when they ask or while scheduling health care services. The services provided at Rooted Therapies fall into this category.

Note: The PHSA and GFE do not currently apply to any individuals who are using insurance benefits, including “out of network benefits” (i.e., submitting superbills to insurance for reimbursement).

Timeline Requirements

Providers must provide a Good Faith Estimate (GFE) of anticipated charges for scheduled services, including likely accompanying services, within specific timeframes:

– For services scheduled at least 3 business days in advance, the GFE must be given within 1 business day after scheduling.

– For services scheduled at least 10 business days in advance, it should be provided within 3 business days after scheduling.

– No GFE is needed for services scheduled with less than 3 business days’ notice.

– If an uninsured or self-pay patient requests a GFE without scheduling, it must be provided within 3 business days.

– If a patient reschedules, a new GFE must be provided within the required timeframes.

Estimating the duration of a client’s therapeutic treatment can be complicated and depends on the individual and their goals. Some clients may be satisfied with a decrease in symptoms, while others continue for longer due to perceived benefits. Many may reduce their visits but still come in for “check-ins” when needed. Ultimately, the decision to end therapy is yours as the client.

Common Services at Rooted Therapies, LLC

90791: Intake Assessment (approx. 45-60 minutes)
90837: Psychotherapy, 60 min (53-60 minutes)
90834: Psychotherapy, 45 min (38-52 minutes)
90846: Family/Couples Psychotherapy without patient (approx. 45-60 minutes)
90847: Family/Couples Psychotherapy with patient (approx. 45-60 minutes)

Common Diagnosis Codes at Rooted Therapies, LLC

The list below includes common diagnosis codes utilized at Rooted Therapies; however, it is not comprehensive. It is important to note that diagnosis codes may vary based on various factors. Please reach out to your counselor if you have any questions or concerns.

F43.xx Adjustment Disorder
F32.xx Depression
F41.xx Anxiety
F43.xx Post Traumatic Stress Disorder
F31.xx Bipolar Disorder
F90.xx ADHD

At Rooted Therapies, a diagnosis is required for clinical, ethical, legal, and insurance purposes, in line with the “No Surprise Act.” Until you are evaluated, your Good Faith Estimate (GFE) will include one of the following:

Primary Diagnosis: F99. Mental Health Disorder, Not Otherwise Specified; Adjustment Disorder (F43.23)
Secondary Diagnosis: Z73.3 Stress, Not Otherwise Specified

These diagnoses are for GFE requirements and do not reflect a formal psychological diagnosis, which will be established after your initial assessment within 1 to 5 sessions. If you choose not to get a formal diagnosis, the GFE will remain unchanged. You have the right to decline a diagnosis as per state and federal regulations (Fl. Sta. 381.025(4)(b)4; Amdt 14.S1.6.5.1).

Length of Therapy

Rooted Therapies, LLC recognizes that each person’s mental health journey is unique. The number of sessions you need will depend on several factors, including:

Intensity of your symptoms
Your time availability and life situation
Current challenges
Specific issues and your approach
Financial considerations
Counselor availability

You and your therapist will regularly assess the frequency of sessions and collaborate on your progress toward goals. If your needs change, a new “Good Faith Estimate” can be provided.

The American Psychological Association indicates that 15 to 20 sessions are typically needed for 50 percent of patients to experience recovery. Some clients may prefer longer durations, such as 20 to 30 sessions, for more comprehensive symptom relief.

Ultimately, the number of sessions varies based on individual counseling goals, and building a therapeutic relationship requires time and collaboration to achieve those objectives. Our focus will always be on addressing your needs.

Location of Services:

We offer in-person sessions at our office at 2562 Commerce Parkway, Unit B, North Port, FL 34289. We also offer telehealth/virtual sessions throughout the entire state of Florida through our secure HIPAA compliant platform, Simple Practice.

Address:

2562 Commerce Parkway, Unit B, North Port, FL 34289

Provider Information:

Provider Name: Rooted Therapies, LLC
NPI: 1477219400
Tax ID: 88-0648969
Email: info@rootedtherapies.org
Phone: 941-216-1406

Clinician Level and Cost of Therapy:

Service	Licensed Clinical Social Worker or Mental Health Counselor	Registered Clinical Social Work or Clinical Mental Health Counselor Interns	Clinical Intern
90791: Intake Session (55 mins)	$200	$50-250 (dependent on counselor)	$0*
90837: Individual Psychotherapy session (53+ min)	$200	$50-125	$0
90834: Individual Psychotherapy session (45-50 min)	$200	$50-125	$0
90847: Family/Couples Therapy with Client Present	$250	$50-150	$0
90846: Family/Couples Therapy without Client Present	$200	$50-150	$0
EMDR Intensive Session Per Hour Rate**	N/A	$125	N/A

*Occasionally we do see clients for less than the above prices, under special circumstances. This is through our sliding scale application or through a client being assigned to a clinical intern. Please note that these prices above are the current maximums that clients will ever have to pay per session out-of-pocket.

**EMDR Intensives (EMDR therapy provided over the course of one or more days usually lasting six hours) are developed specific to the client; rates depend on the number of days/hours per day dedicated to therapy. Client travel and lodging costs are not included in the intensive rate. Rates for off-site intensives are calculated on a case by case basis. An individualized GFE will be furnished to Intensive clients.

Estimated Costs of Services:

The majority of our clients attend therapy sessions once a week, with no more than two sessions a week scheduled, and typically not less than one session every other week, unless exceptional circumstances arise. Below are the costs based on one session per week, calculated for a 52-week period. Please note that while we do not offer formal 30-minute sessions, they may occur in emergencies.

To estimate costs:

One session per week: Intake session ($200) plus 45–50-minute psychotherapy session ($200) totals $10,400 annually.
One session per week: Intake session ($50) plus 53+ minute extended psychotherapy session ($50) totals $2,500 annually.

These examples reflect the expected financial obligations. We customize the frequency and duration of sessions to meet your needs. For questions about the “No Surprises” Act and Good Faith Estimates, feel free to contact us at ‪(941) 216-1406 or email info@rootedtherapies.org.

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 we 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 your counselor directly or Rooted Therapies, 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 required of you 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. You may also contact us directly at 941-216-1406.

The GFE is not a contract. It does not obligate you to accept the services listed on it.

Keep a copy of the Good Faith Estimate (GFE) provided to you 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.