Good Faith Estimate of Costs

You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you under the federal No Surprises Act. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides a range of estimates of the cost of services provided.
You may choose to schedule a range therapy appointments over the course of the next 12 months based on your progress in therapy, potential changes to the goals of therapy over time, unexpected stressors that arise, diagnostic changes, time off for vacation or illness, etc. The pricing listed below is meant to provide a transparent estimate of the costs to you over the next 12-months according to a range of potential frequencies of visits.
Deciding how many appointments (and thus the expenses accrued) is always your choice. Your account will be billed weekly for any services you receive, and as a result there will never be a surprise outstanding balance for you to pay. If you have any questions about the estimated costs listed below, please ask us.
Expiration Date: 12 months from date of issue

DETAILED ESTIMATED COSTS:Your total cost for treatment is the combination of any 45-minute services scheduled/received over the next 12 months PLUS any 55-minute services scheduled/received over the next 12 months. These services are billed at different rates due to different lengths of time with your therapist. This estimate does not include any fees for late rescheduling or canceling of appointments described in office financial policies given to you when you scheduled your first appointment.

For any 45-minute services (which are billed at $175 per appointment) including Individual Psychotherapy (CPT code 90834)Total estimated charges for 2 sessions/week: -1 Week of Service, $350 -13 Weeks of Service (Approx. 3 Months), $4,550 -26 Weeks of Service (Approx. 6 months), $9,100 -39 Weeks of Service (Approx. 9 months), $13,650 -52 Weeks of Service (Approx. 12 Months), $18,200
Total estimated charges for 1 session/week: -1 Week of Service, $175 -13 Weeks of Service (Approx. 3 Months), $2,275 -26 Weeks of Service (Approx. 6 months), $4,550 -39 Weeks of Service (Approx. 9 months), $6,825 -52 Weeks of Service (Approx. 12 Months), $9,100
Total estimated charges for 1 session/ 2 weeks (approx. 2/month): 1 Week of Service, $0-$175 13 Weeks of Service (Approx. 3 Months), $1,138 26 Weeks of Service (Approx. 6 months), $2,275 39 Weeks of Service (Approx. 9 months), $3,413 52 Weeks of Service (Approx. 12 Months), $4,550

For any 55-minute service (which are billed at $200 per appointment) including Individual Psychotherapy (CPT code 90837) Couples/Marriage Therapy (CPT code 90847)
Total estimated charges for 2 sessions/week: 1 Week of Service, $400 13 Weeks of Service (Approx. 3 Months), $5,200 26 Weeks of Service (Approx. 6 months), $10,400 39 Weeks of Service (Approx. 9 months), $15,600 52 Weeks of Service (Approx. 12 Months), $20,800
Total estimated charges for 1 session/week: 1 Week of Service, $200 13 Weeks of Service (Approx. 3 Months), $2,600 26 Weeks of Service (Approx. 6 months), $5,200 39 Weeks of Service (Approx. 9 months), $7,800 52 Weeks of Service (Approx. 12 Months), $10,400
Total estimated charges for 1 session/ 2 weeks (approx. 2/month): 1 Week of Service, $0-$200 13 Weeks of Service (Approx. 3 Months), $1,300 26 Weeks of Service (Approx. 6 months), $2,600 39 Weeks of Service (Approx. 9 months), $3,900 52 Weeks of Service (Approx. 12 Months), $5,200
Your total cost for treatment is the combination of any 45-minute services scheduled/received over the next 12 months PLUS any 55-minute services scheduled/received over the next 12 months. This estimate does not include any fees for late rescheduling or canceling of appointments described in office financial policies given to you when you scheduled your first appointment.

DISCLAIMER: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 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.
Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional service costs are in addition to the Good Faith Estimate.
If your needs change during treatment, your provider should supply a new, updated Good Faith Estimate to reflect the changes to treatment, and the accompanying cost changes.
You may contact the health care provider or facility listed 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.
The Good Faith Estimate is not a contract between provider and client and does not obligate or require the client to obtain any of the listed services from the provider.
You have a right to initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS) if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). 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 HHS at (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 (800) 985-3059.


Provider name: Landrie Ethredge, Licensed Professional Counselor (LPC) Business: Landrie H Ethredge Professional Counseling, LLC Street address: 125-E Wappoo Creek Drive City: Charleston State: SC ZIP code: 29412 Phone: 843.410.9046 Email: moc.egderhtEeirdnaL%40tcatnoc National Provider Identifier (NPI): 1437709136 Taxpayer Identification Number (TIN): 84-3220211