Good Faith Estimate - Ketamine Assisted Psychotherapy
Please note this information is provided to you in accordance with the No Surprises Act introduced January 1, 2022, and outlines your potential total costs for psychotherapy services. Please know we never pre-charge for sessions or bill in advance. Session fees are only charged for a session you schedule and attend or if you cancel your session with less than 48 hours notice.
Good Faith Estimate Notice
You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health 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 expected charges for medical services, including ketamine assisted psychotherapy services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including ketamine assisted psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a 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.
Provider Info:
Kim Burris, Licensed Marriage and Family Therapist, LMFT #98927. 1037 Suncast Lane #110, El Dorado Hills, CA 95762. 916.467.9539. kim@theholisticcounseling.center. NPI# 1255818837.
Perri Griffin, Associate Marriage and Family Therapist, AMFT #127743. 1037 Suncast Lane #110, El Dorado Hills, CA 95762. 916.209.0230. perri@theholisticcounseling.center . NPI# 1871148809.
Fees
You are entitled to receive this “Good Faith Estimate” of what the charges for ketamine assisted psychotherapy services provided to you could be. While it is not possible for a psychotherapist to know, in advance, how many sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services for ketamine assisted psychotherapy services. Your total cost of services will depend upon the number of ketamine assisted psychotherapy sessions sessions you attend. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.
This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of ketamine assisted psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
The fees for ketamine assisted psychotherapy are outlined below. You are only charged for each session that you attend and there is no commitment or pre-payment required.
Fees and Estimated Costs for Ketamine Assisted Psychotherapy:
Fees:
Ketamine Preparation Session (50 minutes):
Kim Burris: $250
Perri Griffin: $170
Guided Ketamine Journeys (3 hours each):
Kim Burris: $700
Perri Griffin: $500
Ketamine Therapy Integration Session (50 minutes):
Kim Burris: $250
Perri Griffin: $170
Please notes ketamine assisted psychotherapy at The Holistic Counseling Center does not include a medical intake, medicine or medical follow-up appointments. We are partnered with Journey Clinical for these services.
Estimated costs for Journey Clinical services includes:
Medical Intake: $250
Ketamine Medicine: $25
Medical Follow-up Appointment: $150
Estimated Costs:
Estimated total costs for 2 ketamine treatments with Kim: $2,825
1. Individual Medical Intake, medicine, and follow-up appointment with Journey Clinical:
$425
2. 2 Ketamine Preparation Session: $500
3. 2 Guided Ketamine Journeys (3 hours each): $1,400
4. 2 Individual Therapy Integration Sessions (50min each): $500
Estimated payment to Journey Clinical: $425
Estimated payment to The Holistic Counseling Center: $2,400
Estimated total costs for 2 ketamine treatments with Perri: $2,530
1. Individual Medical Intake, medicine, and follow-up appointment with Journey Clinical:
$425
2. Ketamine Preparation Session: $340
3. 2 Guided Ketamine Journeys (3 hours each): $1000
4. 2 Individual Therapy Integration Sessions (50min each): $340
Estimated payment to Journey Clinical: $425
Estimated payment to The Holistic Counseling Center: $1,680
Please note we have a 48-hour cancellation policy for ketamine assisted psychotherapy. If you cancel or reschedule your appointment with less than 48 hours’ notice, we do charge a full session fee.
Your Good Faith Estimate will be reassessed yearly.
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 listed above 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. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises.
You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.