Date of Client Contact:
Date of Good Faith Estimate:
Good Faith Estimate
This is NOT a legally binding contract. Any client can stop treatment when they wish and NOT be financially responsible for any appointments beyond the end of treatment.
Provider: Joanna Poppink, MFT
NPI:1427713270 EIN 87-4229305
Physical Location: 10573 West Pico Blvd. #20, Los Angeles, CA 90064
Alternate Location: POS 10 or 02 for telehealth
Common Diagnosis Codes: Below are common diagnosis codes; however, the list is not exhaustive. With that said, diagnosis codes can change based on many factors. Please let me know if you have any questions or concerns.
(See more complete list of possible diagnoses at end of this document)
Joanna recognizes every client's situation, readiness and background contributing to her therapy journey is unique. How long you need to engage in therapy and how often you attend sessions will be influenced by unexpected or changing circumstances. If increased stress and anxiety develops during the challenging process of depth psychotherapy, it is not unusual for a client to request extra sessions and/or increase frequency of sessions.
Together we will continually assess the appropriate frequency of therapy and will work to determine when you have met your goals and are ready for discharge.
Where services will be delivered.
• I am currently only providing services via telehealth until further notice; as such, all benefits will be quoted as virtual unless indicated otherwise in the notes section of this document.
This Good Faith Estimate is specifically tailored for:
Date of Birth: _______________________________________________________________
Client’s Contact Preference: Rank in order 1, 2, 3, 4.
Post ______ Text______ Phone _____ Email _____
As a therapist, I must diagnosis clients for both ethical, legal, and insurance reasons -- as well as required by the "No Surprises Act."
Your Good Faith Estimate diagnosis is:
Z13.30 Encounter for screening for mental health diagnosis
This diagnosis is only to satisfy the federal requirement for this form and is not a formal psychological diagnosis. A formal diagnosis occurs after an assessment has been completed, which typically occurs 1-5 sessions after beginning psychotherapy. If you choose to decline a formal diagnosis, I will not update this GFE.
It is within your rights to decline a diagnosis per state and federal guidelines.
Your Financial Responsibility Summary
For a good faith estimate: the amount you would owe if you were to attend therapy for 52 sessions in a year (weekly, without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc.). The "Good Faith Estimate" requires practitioners to provide an exact estimate and not a range.
Out of an abundance of caution and transparency, I will only quote weekly appointments.
Service: Individual Therapy 38-52 minutes
Billing Code: 90834
Provider Charge: $275.00
Good Faith Estimate Disclaimers:
• This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
• This Good Faith Estimate is designed for public information on Joanna Poppink’s website. After your initial free consultation with Joanna you will receive a personalized Good Faith Estimate tailored to your agreement with Joanna.
• 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.
• The Good Faith Estimate does not include services not provided by your provider that you may need and that your provider may recommend. For instance, the Good Faith Estimate does not include the cost of seeking medication for mental health.
• The Good Faith Estimate is an estimate for services only and does not include other fees, such as fees for cancelling less than 24 hours in advance. These fees are outlined in the informed consent that is signed before the start of therapy services and that you have control over.
• This Good Faith Estimate is not a contract and does not obligate you to receive the services listed nor does it obligate you to receive the services listed by this provider.
• If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
• You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, 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 Good Faith Estimate. 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 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 800-985-3059.
- Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
ICD-10 Mental Health Billable Diagnosis Codes in Alphabetical Order by Description Last updated 11/6/17 Page 1 of 17 IICD-10 Mental Health Billable Diagnosis Codes in Alphabetic Order by Description Note: SSIS stores ICD-10 code descriptions up to 100 characters. Actual code description can be longer than 100 characters. ICD-10 Diagnosis Code ICD-10 Diagnosis
F41.0 Panic Disorder (episodic paroxysmal anxiety)
F43.0 Acute stress reaction
F43.22 Adjustment disorder with anxiety
F43.21 Adjustment disorder with depressed mood
F43.24 Adjustment disorder with disturbance of conduct
F43.23 Adjustment disorder with mixed anxiety and depressed mood
F43.25 Adjustment disorder with mixed disturbance of emotions and conduct
F43.29 Adjustment disorder with other symptoms
F43.20 Adjustment disorder, unspecified
F50.82 Avoidant/restrictive food intake disorder
F51.02 Adjustment insomnia
F40.02 Agoraphobia without panic disorder
F40.00 Agoraphobia, unspecified
F50.02 Anorexia nervosa, binge eating/purging type
F50.01 Anorexia nervosa, restricting type
F50.00 Anorexia nervosa, unspecified
F41.9 Anxiety disorder, unspecified
F50.2 Bulimia nervosa
F60.7 Dependent personality disorder
F48.1 Depersonalization-derealization syndrome
F50.9 Eating disorder, unspecified
F40.231 Fear of injections and transfusions
F41.1 Generalized anxiety
F48.9 Nonpsychotic mental disorder, unspecified
F50.8 Other eating
F41.3 Other mixed anxiety
F43.8 Other reactions to severe stress
F45.8 Other somatoform disorders
F32.89 Other specified depressive episodes
F50.89 Other specified eating disorder
F41.8 Other specified anxiety disorders
F43.12 Post-traumatic stress disorder, chronic
F43.10 Post-traumatic stress disorder, unspecified
F51.9 Sleep disorder not due to a substance or known physiological condition, unspecified
F51.4 Sleep terrors [night terrors
F45.0 Somatization disorder
F45.9 Somatoform disorder, unspecified
F45.7 State of emotional shock and stress, unspecified