Notice of Your Right to Receive a Good Faith Estimate

Under the No Surprises Act, individuals who do not have health insurance or who choose not to use their health insurance to pay for services have the right to receive a Good Faith Estimate of expected charges.

If you are uninsured or plan to pay for psychotherapy services yourself without using insurance, you may request a Good Faith Estimate before scheduling services. You will also receive a Good Faith Estimate when required by federal law after scheduling services.

Because the length and frequency of psychotherapy vary depending on each client’s needs, it is not possible to predict in advance exactly how many sessions you may attend. Your individualized Good Faith Estimate will reflect the information available at the time it is prepared and may be updated if the anticipated frequency, duration, or cost of services changes.

Session Fees

Individual Therapy (50 minutes): $250 per session

Couples Therapy (75 minutes): $375 per session

Most clients attend therapy once per week, although frequency may vary depending on your goals, needs, and treatment plan.

A Good Faith Estimate is not a contract and does not require you to receive services from Orrick Marriage and Family Therapy Professional Corporation (DBA Libby Orrick Therapy).

Your Rights

If you receive a bill from a provider that is at least $400 more than the amount listed on your Good Faith Estimate for that provider, you may be eligible to use the federal patient-provider dispute resolution process.

You generally must begin the dispute process within 120 calendar days of the date on the initial bill. An independent third party will review the dispute and determine the appropriate payment amount.

For more information about your right to receive a Good Faith Estimate or the patient-provider dispute resolution process, visit www.cms.gov/nosurprises or call the federal No Surprises Help Desk at 1-800-985-3059.