Under the No Surprises Act, you have the right to know the expected cost of your care before your first session. This page explains your rights and provides a downloadable estimate template.
Download GFE Template (PDF)Federal Law Requirement: You have the right to receive a Good Faith Estimate in writing at least 1 business day before a medical service or item. You can also ask your health care provider for a GFE before you schedule an item or service. Learn more at cms.gov/nosurprises
A Good Faith Estimate (GFE) is a written notice that outlines the expected costs of your healthcare services before you receive them. Under the No Surprises Act (effective January 1, 2022), all healthcare providers — including mental health therapists — are required to provide a GFE to uninsured patients or those who choose not to use their insurance.
You are entitled to a Good Faith Estimate if you are uninsured, if you are self-paying (paying out-of-pocket without using insurance), or if you choose not to use your insurance for a particular service. If you are using in-network insurance, your insurer's Explanation of Benefits (EOB) serves a similar purpose.
The estimate includes the expected cost per session, the CPT billing codes for each service type, the anticipated number of sessions over a 12-month period, and the total estimated cost. It also identifies your provider's name, license numbers, NPI, and contact information.
If you receive a bill that is $400 or more above the Good Faith Estimate, you have the right to dispute that bill. To initiate a dispute, visit cms.gov/nosurprises or call 1-800-985-3059. You must start the dispute process within 120 calendar days of receiving your bill.
To receive a personalized Good Faith Estimate before your first session, simply contact Marilu's office by phone or email. A completed estimate will be provided to you at least one business day before your scheduled appointment, or upon request at any time.
GFE Template
3-page PDF · Fillable
Download the blank template to review before your consultation. Marilu will complete a personalized copy for you before your first session.
Download PDFContact Marilu before your first session to receive a personalized Good Faith Estimate tailored to your specific services.
Dispute Rights
If your bill exceeds this estimate by $400 or more, you can dispute it within 120 days of receiving the bill. Visit cms.gov/nosurprises or call 1-800-985-3059.
These are Marilu's standard self-pay rates. If you are using insurance, your actual cost will depend on your plan's copay, deductible, and coinsurance.
| Service | CPT Code | Self-Pay Rate |
|---|---|---|
| Individual Psychotherapy (60 min) | 90837 | $165 |
| Individual Psychotherapy (45 min) | 90834 | $140 |
| Individual Psychotherapy (30 min) | 90832 | $110 |
| Couples / Family Therapy (60 min) | 90847 | $190 |
| Initial Intake / Assessment (60 min) | 90791 | $175 |
| EMDR – Individual Session (60 min) | 90837+ | $165 |
| Phone / Video Check-In (20 min) | 99442 | $75 |
Book a free 15-minute consultation and receive your personalized Good Faith Estimate before your first session.