Good Faith Estimate
Last updated June 20, 2023
Brief explanation of estimate for new patients:
The estimate below is the range of costs that is likely for most new patients. Until I do an initial evaluation and we start to work together, I will not have a clear picture of your specific diagnosis, issues and needs. I typically see therapy patients for 6-20 sessions for a total cost of $1200 for short term treatment (6 sessions), $2800 for average treatment of an anxiety disorder (14 sessions), and $4000 for long-term treatment (20 sessions). But in some cases, a patient’s issues may be more complicated, so we may need additional sessions during the time covered by this estimate.
Contact: If you have questions about this estimate, please contact Dr. D’Souza at drdsouza@valuesfirsttherapy.com.
Details of the Estimate
The following is a detailed list of expected charges for psychological services scheduled. The estimated costs are valid for 12 months from the date of this Good Faith Estimate, unless we send you an updated Estimate.
Initial evaluation (CPT code 90791): $200. Quantity: 1.
Psychotherapy (CPT code 90837 and/or 90834): $200. Quantity: 6-20.
Total estimated cost: $1200-4000.
Psychologist providing services: Johann D’Souza
NPI number: 1396455259
TIN:
Address of office from which services will be provided:
5900 Memorial Drive, Suite 218, Houston, TX 77007
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 the psychology practice 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 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.
This GFE is not a contract. It does not obligate you to accept the services listed above.
Keep a copy of this Good Faith Estimate (GFE) 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.