Good Faith Estimate

Dear Client and Prospective Client,

In compliance with the No Surprises Act that went into effect on January 1, 2022, healthcare consumers who don’t have insurance or who are not using their insurance have a right to receive a Good Faith Estimate for the total expected cost of any non-emergency medical items or services. The No Surprises Act also requires Debra Kaplan Counseling to notify all healthcare consumers when services are rendered by a non-participating provider.

IMPORTANT: You aren’t required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider before scheduling care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less.

If you’d like assistance with this document, ask your provider or a patient advocate. Take a picture and/or keep a copy of this form for your records.

You’re getting this notice because Debra Kaplan Counseling isn’t in your health plan’s network and is considered out-of-network. This means Debra Kaplan Counseling doesn’t have an agreement with your plan to provide services.

Getting care from Debra Kaplan Counseling (DKC) will likely cost you more than if you utilize your in-network services.

Additionally, DKC is required to provide you with a Good Faith Estimate of the cost of services for the duration of treatment. It is difficult to determine the exact length and scope of treatment for our work together. Attached is the best estimate based on what is most typical at DKC. Please read and sign the Good Faith Estimate which follows. This estimate is provided in an effort to be as transparent as possible about your potential financial investment in services with DKC.

You may incur fees throughout your care with DKC that are in addition to costs associated with direct services. These fees include, but are not limited to:

  • Late cancellation/no show fee
  • Medical records request
  • Completion of documents (Summary letters, Subpoena and Court Order of documents)
  • Consultation/Coordination of Care

Good Faith Estimate

Primary Diagnosis and Diagnostic Code: To be determined; fee per service will remain the same regardless of diagnosis.

Service CodeDescriptionFrequencyCostTotal
  90791Diagnostic Intake  1-2x  $200 per 50 min.  $200 – $400
90837Individual Therapy Weekly for 52 weeks $160 per 50 min.  $8,320
90837Extended Individal Sessions  Monthly for 10-12 months $320 per 1 hr. 40 min.  $3,200 – 3,840
  90847Family or Conjoint Session  Weekly for 52 weeks$160 per 50 min.  $8,320
Consultation 1-10 hours$200 per 50 min. $200 – $2,000
 Case Consultation  1-10x$40 per 15 min  $160 – $1,600
Total Estimate: $15,260-$20,000


information about how much you will be asked to pay. You also can ask about what’s covered under your plan and your provider options.

Questions about this notice and estimate? Call DKC at 520.203.1943 or email info@debrakaplancounseling.com

More information about your rights and protections: Visit https://www.cms.gov/nosurprises for more information about your rights under federal law. You can also contact the Department of Health and Human Services with questions.

My initials and signature below indicate that I give up my federal consumer protections and agree to pay more for out-of-network care. Ub addition, I agree to get the services indicated from Debra Kaplan Counseling.

  • With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I understand that I am giving up some consumer billing protections under federal law.
  • I will get a bill for the full charges for these items and services and not contribute to my in-network cost-sharing under my health plan.
  • I was given written notice on __________________________.
  • I got the notice either on paper or electronically, consistent with my choice.
  • I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out of pocket limit.
  • I can end this agreement by notifying Debra Kaplan Counseling as per the Consent Agreement terms in writing before getting services.

Client Name:
Client Signature:

Date: