Good Faith Estimate (No Surprises Act)

Tara Sedov, LICSW
9757 NE Juanita Dr., Suite 214
Kirkland, WA 98034
United States
NPI 1699121616

The estimate below is the cost that is likely for most new patients receiving therapy services. This document does not apply to supervision, consultation, expat coaching, or other services, other than therapy. This is only for US-based therapy clients in states this therapist is licensed to provide therapy in. 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 patients for a range sessions. But cases may be more complicated, so we may need additional sessions during the time covered by this estimate.

If you have questions about this estimate, please contact me.

Details of the Estimate

Initial Evaluation (90791)

Address where service will be provided: Virtually/Telehealth
Diagnosis Code (ICD-10): UNKNOWN
Service code: 90791
Quantity : ONE
Expected Cost: $200 USD

Additional notes:
Tara Sedov, LICSW will provide an updated Good Faith Estimate after the intake assessment with the estimate for the cost of sessions as Tara Sedov can not accurately estimate the cost of care without first meeting and assessing an individual seeking care. A diagnosis can change as we continue to work together and if that changes the estimate of cost, Tara Sedov will update the estimate.

Therapy sessions (90832, 98034 or 90837)

Address where service will be provided: Virtually/Telehealth
Diagnosis Code (ICD-10): UNKNOWN
Service code: 90832, 90834, 98037 (depending on length of therapy session)
Quantity : WEEKLY (50 weeks)
Expected Cost: $175 x 50 = $8,750 USD (If seen weekly, every week for most of the year less estimated vacations, sick time, holidays)

Total Expected Charges from Tara Sedov: $8,750 (Not counting the initial intake)

Additional notes:
A diagnosis is given after the initial intake assessment to provide this estimate of care. A diagnosis can change as we continue to work together and if that changes the estimate of cost, Tara Sedov will update the estimate.

Please keep in mind, determining exactly how many sessions of therapy will be needed is difficult. Effective therapy can range from 12 sessions to 30 or more sessions. For many, therapy is ongoing. 

Total Estimated Cost : $8,950

Disclaimer

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 us when we 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 contact listed above if billed charges are higher than the Good Faith Estimate. You can request an update to 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.