No Surprise Act Disclosure and Patient Rights
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities
are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.
Effective as of: January 1, 2022
Common Services at Head and Heart Therapy:
90791: Initial Assessment
90834/7: Individual Psychotherapy session
90847: Family/Couples Psychotherapy session
90846: Family/ Couples Psychotherapy without patient present
Common Diagnosis Codes at Head and Heart Therapy
F32.9: Major Depressive Disorder, Unspecified
F43. 22 Adjustment disorder with Anxiety
F41.1: Generalized Anxiety Disorder
F43.1: Post-Traumatic Stress Disorder (PTSD)
F43.10: PSTD, Unspecified
Z62.820: Parent/Child Relational Conflict
Z63. 0 - Problems in Relationship with Spouse or Partner
Where Services will be Received
Online, via telehealth in NJ or FL. Location of service is determined by client's location at time of session.
Frequency and Quantity of Sessions
At Head and Heart Therapy, I recognize that every person's journey is unique. How long and how how often
you need to engage in therapy can be influenced by several factors:
-Ongoing life challenges
However, estimates of total cost for your "Good Faith Estimate" will be based on a full year of treatment at 48-52 weeks (or 24-26 at bi-weekly) per year, accounting for vacations, holidays, cancellations/sickness.
Cost of Sessions by CPT Code
90791 and 90834: $175/session
90847 and 90846: $250/session
(If a sliding scale has been arranged this rate will be adjusted)
PLEASE NOTE THAT I AM OUT-OF-NETWORK PROVIDER WITH ALL COMMERCIAL INSURANCES AND THAT PAYMENT FOR SERVICES IS SELF-PAY AND DUE AT THE TIME OF SERVICE.
(THE ONLY INSURANCE I PARTICIAPTE WITH IS MEDICARE)
Provider Name: TamiBeth Danzig, LCSW
TAX ID: 84-3960549
Phone #: 551. 587.8451
DISCLAIMERS & YOUR RIGHTS
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
•You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
•Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
•If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
•Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises