Good Faith Estimate

Adjust Mental Health, LLC, FEE AGREEMENT and GOOD FAITH ESTIMATE

No Surprises Act

In compliance with the No Surprises Act that went into effect January 1, 2022, all healthcare providers including psychiatrists and therapists are required to notify patients of their federal rights and

protections against “surprise billing.” The purpose of the Act and of this document is to protect you

from unexpected medical bills.

This Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network psychiatrist or therapist (as we often are), if you are uninsured, or if you elect not to use your insurance.

In case any of these situations apply to you, we are required to provide you with a “Good Faith Estimate” of the cost of services to you. Doing so is particularly challenging in mental health care because it is difficult to predict the length of treatment and because patients have a right to decide how long they want to participate. Therefore, we describe below the fees that typically apply for the types of services we offer, including for your condition. Going forward, we can collaborate on a regular basis to determine how many sessions you may need.

As per our terms and our patient/provider agreement, all patients agree to pay the full rate unless otherwise negotiated before treatment begins or if in-network in which case they agree to pay their copay or coinsurance amounts and meet any necessary deductibles. If no payment is presented at the time of treatment, payment will be billed to the credit card we have on file. After the initial consultation, regular follow-ups are scheduled depending on clinical needs. Depending on your treatment plan and clinical discretion, the frequency of appointments may vary. Note that these rates are subject to change, but in the event of a fee increase, a new Fee Agreement will be presented.

Service Rates:

60-90-minute Initial Psychiatric Evaluation - $339.57

45-minute Initial Psychiatric Evaluation - $288.12

45-minute Medication Management Follow-up - $180.08

30-minute Medication Management Follow-up - $154.35

15-minute Medication Management Follow-up - $128.63

Hourly rate for expert consultation, including forensic or legal document review, and preparation of significant documentation, appearances in court, depositions, and scheduled time addressing legal matters out of the office - $339.57

60-90-minute Initial Psychotherapy Session - $132.63

50-60-minute Subsequent Psychotherapy Session – $124.29

● Most often medication management is done every one to three months, but sometimes more often at the beginning of treatment and during periods of acuity, and sometimes less often.

● Most often medication management continues for several years or even longer; because of this variability, please ask what can be expected in your case.

● For psychotherapy, you and your therapist will determine the frequency of therapy sessions (weekly, biweekly, monthly, etc.)

● It is your right to determine your goals for treatment and how long you want to remain in treatment.

Required Disclaimers:

● Should you have additional questions about your rights under this act, you can contact any of the following: The U.S. Centers for Medicare & Medicaid Services (CMS) at 1- 800-MEDICARE (1-800-633-4227) or visit <https.//www.cms.gov/nosurprises> for more information about your rights under federal law. The Illinois Department of Insurance, Office of Consumer Health Insurance at (877) 527- 9431.

● If you are billed for more than this Good Faith Estimate you have the right to dispute the bill. You may 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 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 healthcare provider, you will have to pay the higher amount.

If you have any questions related to billing, please contact us via admin@adjustmentalhealth.com or speak to your clinician.