Good Faith Estimate for Health Care Items and Services

You are entitled to receive a “Good Faith Estimate” for your expected services from Georgios Asimis, MD. While it is not possible to know in advance how many sessions may be needed or provided to each patient, we have provided this estimate based on what the charges could be for your psychiatric treatment services as of the date above.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a requirement that you need to attend a specified number of psychiatric treatment sessions. The number of recommended sessions will depend on your Initial Evaluation and what you and Georgios Asimis, MD believe is appropriate based on your individual circumstances. The total cost of services may depend on your progress, how many sessions you attend each week, and whether you request additional sessions. You may choose to discontinue your sessions at any time.

Please let Georgios Asimis, MD know if you have questions about your treatment plan, payment options, or the information provided in this Good Faith Estimate.

Estimate Details

The following is a detailed list of expected charges for psychiatric treatment services scheduled for one year.

Expected cost:

Initial Evaluation = $750.00

Psychotherapy + Medication Management: Monthly/Bi-Weekly/Weekly = $4,800.00 to $20,800.00

Straight -Forward Medication Management:  Monthly/Bi-Weekly/Weekly = $2,400.00 to $10,400.00

Disclaimers

This Good Faith Estimate is not a contract. It does not oblige you to receive any services from Georgios Asimis, MD. This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs. The estimate is based on information known at the time the estimate was created.

There may be additional services that are recommended as part of your course of care that must be scheduled or requested separately. Such services are not reflected in this Good Faith Estimate. Separate Good Faith Estimates will be issued upon scheduling or upon request of the items or services listed here:

_                                                                                                                      ________

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

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

If the actual amount charged to you exceeds the costs listed in this Good Faith Estimate, you have the right to dispute the bill. You may contact Georgios Asimis, MD if the billed charges are higher than the Good Faith Estimate. You can ask us to update the bill to match the Good Faith Estimate, negotiate the bill, or ask if there is financial assistance available.

You may also use the 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 four months) of the date on the original bill. There is a $25 fee to use the dispute process. Initiating the dispute resolution process will not adversely affect the quality of the psychiatric treatment services provided by Georgios Asimis, MD.

If the agency reviewing your dispute agrees with you, you will have to pay the estimated total for services provided on this Good Faith Estimate. If HHS disagrees with you and agrees with Georgios Asimis MD, you will be obligated to pay the higher amount on your bill. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS on 1-800-985-3059.

Keep a copy of this Good Faith Estimate in a safe place or take a picture of it. You will need it if you choose to initiate the dispute resolution process outlined above.

Note: Existing patients may have an established diagnosis and treatment plan; however, prospective, or new patients may not. If enough information is not yet available, Georgios Asimis, MD will make a reasonable attempt, based on information known at the time the estimate is created, to include expected diagnosis and service codes as well as expected charges associated with the service(s).