Evergreen Therapy Center
NPI 1043828825

FEDERAL LAW REQUIRES US TO GIVE YOU AN ESTIMATE OF THE COST OF SERVICES IF YOU DON’T HAVE OR USE INSURANCE. THIS IS AN ESTIMATE OF WHAT PSYCHOTHERAPY WOULD COST IF YOU ATTENDED A TYPICAL COURSE OF THERAPY (AVERAGE OF 15 SESSIONS). THIS IS NOT A BILL NOR DO YOU OWE US THE ESTIMATE LISTED ON THIS BILL. THIS IS JUST AN ESTIMATE OF CHARGES IF YOU DECIDED TO ATTEND 15 SESSIONS IN THE COMING YEAR. YOU MAY ATTEND MORE OR FEWER SESSIONS.

DIAGNOSES & CODE:

The price of our services is the same, regardless of your diagnosis. Therefore, we only list the cost of therapy for the kind of appointment you are having.

SERVICE(S) TO BE SCHEDULED BY AND COST OF SERVICE BY PROVIDER'S DEGREE:

	Social Worker, Mental Health Counselor, Marriage and Family Therapist	Psychologist
90791 (INTAKE ASSESSMENT)	$187	$197
90837 (53+ MINUTE SESSION)	$157	$166
90834 (33-52 MINUTE SESSION)	$157	$166
90832 (16-32 MINUTE SESSION)	$130	$130

ESTIMATED NUMBER OF SESSIONS: 15 weekly sessions.

ESTIMATED COST OF SERVICES: One “Intake” AND fourteen “53+Minute sessions” with a psychologist is $2,521.

ESTIMATED COST OF SERVICES: One “Intake” AND fourteen “53+Minute sessions” with a social worker, mental health counselor, or marriage and family therapist $2,383.

*This estimate is good for 12 months from the date identified above*

Psychologist

Jason Drwal: 1164669594

Jaci Rolffs: 1497274260

Social Worker, Mental Health Counselor, Marriage and Family Therapist

Christine Topping (Marriage and Family Therapist): 1417357583

Julie Peterson (Social Worker): 1619516960

Katie Burrell & Miranda Juarez (Social Workers): Under the supervision of Julie Peterson

Natalie Quinn (Social Worker): 1982111761

Julie Jack: 1356105514

Kerstin Marnin: 1891365631

Mallory Markwitz: 1902446305

Natalie Quinn: 1982111761

Alexandra (Lexy) Howell: 1497360374

 

CLINIC PHONE #:319-853-8762

CLINIC EMAIL: scheduling@evergreentherapycenter.com

DISCLAIMER

This Good Faith Estimate (GFE) shows the costs of services that are reasonably expected for your health care needs. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. Refer to the Informed Consent document for potential ‘out-of-session’ costs including a $50 no show/late cancel fee, phone calls lasting longer than 15 minutes, and any court-related services. These ‘out of session’ costs cannot be pre-determined and are therefore not included in this GFE. You are responsible for charges related to special circumstances that may change the above-identified estimate. Federal law regarding the “No Surprises Act '' allows you to dispute the bill if it is different from the above-identified estimate. You may contact the health care provider and/or facility listed above to let them know that the billed charges are higher than the GFE. You have the following rights: (1) ask them to amend the charges to match the GFE; (2) ask to negotiate the bill and/or ask if financial assistance is available; (3) dispute the resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to dispute the billed charges, you must begin your dispute within 120 calendar days 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 be responsible for the amount listed on this GFE. If the reviewing agency disagrees with you and upholds the bill administered by your healthcare provider and/or facility, you will be responsible for the billed amount, even if it is higher than the estimated costs on the original GFE. To learn more and/or obtain a form to begin the appeal process, go to www.cms.gov/nosurprises or call HHS.

Provider Signature

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