GOOD FAITH ESTIMATE (GFE) FOR HEALTHCARE SERVICES
Ruth Oluwole, MSN, PMHNP-BC
Phone: (832) 520-2452 | Email: info@starrypsychiatrywellness.com
PURPOSE OF THIS GOOD FAITH ESTIMATE
You are receiving this Good Faith Estimate because you are:
- Uninsured, or
- Choosing not to use your insurance for these services
Under federal law, healthcare providers must provide a Good Faith Estimate of expected charges for scheduled non-emergency services. This estimate is intended to help you understand the anticipated costs of your care and make informed decisions.
DESCRIPTION OF SERVICES
Primary service(s) expected to be provided:
Expected start date of service: Date of initial appointment
Expected duration of care: up to 12 months (May vary depending on clinical needs)
Diagnosis: To be determined following initial evaluation
Diagnosis (ICD-10 Code, if available): Not available at initial estimate
ESTIMATED CHARGES
The following is a good faith estimate of expected charges for services reasonably anticipated based on your current treatment plan:
| Initial psychiatric evaluation (60-90 minutes) | $200 |
| Follow-up medication management (20-30 minutes) | $125 per visit |
| Extended Follow-Up (45-60 minutes) | $150 per session |
| Medication management (if applicable) | $________ per visit |
| Telehealth services (if applicable) | $0 per visit |
| Additional anticipated services (Medication refills, forms, letters) | May incur fees |
TOTAL ESTIMATED COST (12 months)
Depending on treatment frequency and clinical needs. This estimate reflects services reasonably expected at this time.
RECURRING SERVICES (IF APPLICABLE)
If your care includes ongoing treatment, this estimate may include recurring services for up to 12 months.
Estimated frequency of visits: 2-4 weeks during initial treatment, 1-3 months once symptoms are stable
Estimated number of visits: 6-12 visits during the first year of treatment
SERVICES NOT INCLUDED IN THIS ESTIMATE
This estimate does not include services that are not reasonably expected at this time, including but not limited to:
- Laboratory or diagnostic testing
- Psychological or neuropsychological testing
- Higher levels of care (intensive outpatient, partial hospitalization, inpatient treatment)
- Emergency services
- Services provided by other providers or facilities
IMPORTANT DISCLAIMERS
- This Good Faith Estimate is not a contract and does not obligate you to receive services from this provider.
- The estimate is based on information known at the time and may change based on your clinical needs.
- Actual charges may differ depending on the course of treatment.
- Additional services not listed may be recommended during care.
YOUR RIGHTS UNDER THE NO SURPRISES ACT
You have the right to receive a Good Faith Estimate for the total expected cost of non-emergency healthcare services.
If you receive a bill that is at least $400 more than this estimate, you have the right to dispute the charges.
Patient-Provider Dispute Resolution (PPDR)
You may initiate a dispute within 120 calendar days of receiving the bill. To learn more or start a dispute process, visit:
www.cms.gov/nosurprises
TIMING OF THIS ESTIMATE
- Within 1 business day if services are scheduled 3–9 business days in advance
- Within 3 business days if scheduled 10 or more business days in advance
- Within 3 business days of request if no appointment is scheduled
UPDATES TO THIS ESTIMATE
If your treatment plan or expected charges change, you may receive an updated estimate no later than 1 business day before scheduled services.
QUESTIONS AND CONTACT INFORMATION
If you have questions about this estimate, please contact:
Starry Psychiatry & Wellness PLLC
Ruth Oluwole, MSN, PMHNP-BC
Phone: (832) 520-2452 | Email: info@starrypsychiatrywellness.com