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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.

  • Adjustment Disorder (F43.23)
  • Bulimia nervosa (F50.2)
  • Social Anxiety Disorder (F40.10)
  • PTSD (F43.10)
  • Depression (F32.0-F33.3)
  • OCD (F42.9)
  • Generalized Anxiety Disorder (F41.1)
  • Eating disorder, unspecified (F50.9)
  • Anorexia (F50.02; F50.00)
  • Sleep terrors (F51.4)
  • Somatization disorder (F45.0)
  • State of emotional shock and stress, unspecified (F45.7)

(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.

 

Client Information

This Good Faith Estimate is specifically tailored for:

 

Name: ____________________________________________________________________

Date of Birth: _______________________________________________________________

 

Client’s Contact Preference: Rank in order 1, 2, 3, 4.

Post ______ Text______ Phone _____ Email _____

Client Diagnosis

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

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