Good Faith Estimate

This estimate is for psychotherapy services through December 31, 2024 (for calendar year 2024), in accordance with the "No Surprises Act".

The estimate below is the typical maximum cost that is likely for most new clients. Until I do an initial evaluation and we start to work together, I will not have a clear picture of your specific diagnosis, issues and needs. I typically see therapy clients for weekly 55-minute sessions ($250) for a total annual cost of $13000. But in some cases a client’s issues may be more or less complicated, so we may need additional or fewer sessions during the time covered by this estimate.

Brief explanation for continuing clients: The estimate below is the cost that I think is likely for your care based on weekly sessions over the time period covered by this estimate (the current calendar year). However, depending on how treatment progresses, more or fewer sessions may be needed.

Contact: If you have questions about this estimate, please contact Lou A. Lichti, Ph.D. at (p) 301-401-2813 (email) drlou@cityparkpsychological.com.

Details of the Estimate

The following is a detailed list of expected charges for psychological services scheduled for 2024. The estimated costs are valid for 12 months from the date of this Good Faith Estimate, unless I send you an updated estimate.

Service: Initial Evaluation
Service Code: 90791
Diagnosis: TBD
Quantity: 1-3
Cost Per Unit: $280
Expected Cost: $840

Service: Psychotherapy
Service Code: 90837
Diagnosis: TBD
Quantity: 48-52
Cost Per Unit: $250
Expected Cost: $13000

Total estimated cost: $13000-13840

Psychologist providing services: Lou A. Lichti, Ph.D. NPI number: 1215915376 TIN: 52-2138150

This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to me when I did the estimate.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the psychologist at the contact 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 or call CMS at 1-800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059.

This Good Faith Estimate is not a contract. It does not obligate you to accept the services listed above.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed more than $400 than the estimate provided above.