Calm Waters Counseling Services, LLC
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage, both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.
Provider Name: Alyssa LeBlanc, LMHC
Business Name: Calm Waters Counseling Services, LLCv
Address: 300 Andover Street #196, Peabody, MA 0196
Tax ID (EIN): 41-4888636
NPI: 1851512081
Client Name: _____________________________________
Date of Estimate: __________________________________
Estimated Cost of Services
The following is a list of services reasonably expected to be provided. This estimate is based on information known at the time of scheduling.
| Service Type | Estimated Frequency | Cost Per Session | Estimated Total |
|---|---|---|---|
| Initial Intake Assessment (60 min) | 1 (Initial session) | $255.00 | $255.00 |
| Individual Therapy (45-50 min) | Weekly / Bi-weekly | $200 | $200 |
| Family Session (45-50 min) | As needed | $250.00 | $250.00 |
| Parent Consultation (30 min) | As needed | $100.00 | $100.00 |
Important Disclaimers
Estimate Only: This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
Additional Services: 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 the bill.
Right to Dispute: If you receive a bill that is at least $400 more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed above to let them know the billed charges are higher than the Good Faith Estimate. You can 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 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.