BENICIA good faith estimate

What is a Good Faith Estimate of Expectant Charges?

Under the Public Health Service Act, health care providers are required to provide a Good Faith Estimate (GFE) of expectant charges for items and services to individuals who are not seeking to file a claim with their insurance. Here is what you should know about your rights:

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs, such as if you ever need your practitioner to write a letter on your behalf. 

  • Make sure your practitioner gives you a Good Faith Estimate in writing at least 1 business day before your session. You can also ask the practitioner, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

  • Make sure to save a copy or picture of your Good Faith Estimate.

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.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059. You can also call our client experience team at 415-632-1010 ext. 0 to ask questions specific to Connective practitioners and expected service fees.

GOOD FAITH ESTIMATE

PROVIDER FACILITY

The Connective I Benicia
903 First Street
Benicia, CA 94510

Phone: 415-632-1010 ext. 0
Clinic Tax ID: 81-4306180
Clinic NPI: 1083101711

EXPECTED SERVICES RELATED TO DIAGNOSIS (if applicable to the services sought by the client)

The total cost of your care will include the initial intake visit, plus any follow-up visits, and will be paid as you go. The number of visits will vary based on your particular symptoms and/or goals, which will be discussed with your practitioner during your first visit. It is not possible to know in advance how many sessions a person may need given that therapy, nutrition, and coaching require ongoing assessment of treatment progress and goal tracking. You and your practitioner can plan to discuss progress at specific times during the treatment and coaching process (for example, you can decide together to evaluate progress every 3 months/12 sessions). 


DIAGNOSIS (if applicable to the services sought by the client)

To be determined by your provider.


GFE FOR HEALTH CARE: ITEMS AND SERVICES

  • INTAKE: Your treatment at The Connective will include an initial intake assessment. Intakes are typically 60-minute, 75-minutes long, or 90-minutes long. 

  • FOLLOW-UP SESSIONS: Session booked post-intake. Follow-up sessions vary in length of time (see associates rates below) and are booked at a specific cadence (i.e., weekly, bi-weekly) agreed upon by you and your practitioner based on your goals. 

  • MEMBERSHIPS + PACKAGES: These are sessions that have been packaged together and typically include an intake session plus a certain amount of follow-up sessions. Membership and packages may also include other services or offerings such as lab work, meal plans, and/or additional contact with your provider. 

MENTAL HEALTH

PSYCHOTHERAPISTS 

  • Cassie Kellogg, LMFT #150795 (NPI #1013681980)

  • Elizabeth (Liz) Eichmann, LMFT #151067 (NPI #1801561345)

  • Jennifer Roy, Registered Associate MFT #138012 (NPI # 1578251419)
    Supervised by: Dr. Nina Eisenberg, PSY28692 (NPI #1104376748); Nicole Desamparo, LMFT #48275 (NPI 1396896213); & Liz (Hayman) Flick, LMFT #92417 (NPI 1205115995)

  • Marika Yakumithis, Registered Associate MFT #138076 & Registered Associate PCC #13481 (NPI #1750911079 ) 
    Supervised by: Nicole Desamparo, LMFT #48275 (NPI # 1396896213)

  • Nicole Desamparo, LMFT #48275 (NPI # 1396896213)

TIER 1 RATES

Diagnostic Intake/Initial Session: 

  • 90791 Diagnostic Intake/Evaluation (60-90 minute sessions): $230 - $350*

Follow-up Therapy Sessions (Fee is per Session)

  • 90832 Psychotherapy 25 minute check-in session: $115

  • 90834 Psychotherapy 45 minute session: $175

  • 90837 Psychotherapy 60 minute session:  $230  

  • 90837 Psychotherapy 75 minute session:  $290

  • 90837 Psychotherapy 90 minute session:  $350

  • 90847 Family + Couples Psychotherapy w/ client present: $230 - $350*

  • 90846 Family + Couples Psychotherapy w/o client present: $230 - $350*

  • No-show or Late Cancellation (less than 48-hours notice): $115 - $350* 

  • Formal Documentation, per half-hour: $75 Sometimes, clients request formal documentation from therapists when the law or a governing body requires a mental health professional to provide written proof or documentation on your behalf regarding your mental health status or needs (Examples: Medical Leave of Absence, Emotional Support Animal).


    *For session fees marked with an asterisk (*), the fee is dependent on the length of the session (e.g., couples may have 60, 75, or 90 minute sessions). For no-shows and late cancellations, the fee is the exact amount as the fee for the session. There is no additional charge for a no-show/late cancellation.

NUTRITION

CLINICAL NUTRITIONISTS

  • Erica Kirmayer, Certified Nutrition Specialist (NPI #1336882588)

  • Madison Martin, Certified Nutrition Specialist (NPI #1265280135)

CLINICAL NUTRITION RATES

Memberships + Packages:

  • 3 Month Basic Nutrition Membership: $1,280 OR $427 monthly

    • Includes: 90 min. initial session,  5 nutrition coaching sessions to be used within 3 months 

  • 3 Month Nutrition Membership: $2,250 upfront OR $750 monthly

    • Includes: 90 min. initial session,  up to 9 nutrition coaching sessions, 15 minute check-ins as needed

  • 6 Month Nutrition Membership: $4,350 upfront OR $725 monthly

    • Includes: 90 min. initial session,  up to 19 nutrition coaching sessions, 15 minute check-ins as needed

  • 12 Month Nutrition Membership: $7,800 upfront OR $650 monthly

    • Includes: 90 min. initial session,  up to 39 nutrition coaching sessions, 15 minute check-ins as needed

  • Nutrition Membership Re-Up: $1,050 upfront OR $350 monthly (for 3 months)

    • Includes: 90 minutes to be used per month for 3 months, this time can be distributed into:

      • Weekly 20-minute sessions

      • Two 45-minute sessions per month

      • One 90-minute session per month

      • 15 minute check-ins as needed

Single Session Nutrition Rate (Fee is per Session)

  • Holistic Nutrition Intake/Evaluation 90 minute session:$390

  • Holistic Nutrition Session Check-in 30-minutes: $130

  • Holistic Nutrition Session 45 minutes: $195

  • Holistic Nutrition Session 60 minutes: $260

  • Holistic Nutrition Session 75 minutes: $325

  • Holistic Nutrition Session 90 minutes: $390

Meal Plans

  • One week meal plan:  $125

Ordering + Analysis of Advanced Functional Labs 
* Labs may be recommended by your Nutritionist as needed to provide further insight into specific health markers

  • Dutch Test:  $390  - $540 

  • GI Effects Stool Test:  $519

  • Organix® Comprehensive Profile (Organic Acids):  $389

  • Mycotox:  $400

  • GPL-TOX Profile:  $325

  • Glyphosate Test – Urine:  $205

  • Heavy Metals Red Blood Cell Test:  $395

  • Advanced Cholesterol Profile – Serum:  $215

  • Comprehensive Neurotransmitter Profile (NT):  $354

  • DUTCH Cortisol Awakening Response (CAR):  $265

  • Amino Acids Profile:  $234

  • Fatty Acids; Erythrocytes:  $225

  • Metabolomix+ $409 or NutrEval FMV:  $594 (Most comprehensive)

    • Add-On APOE:  $48

    • Add-On COMT:  $48

    • Add-On TNF-a:  $48

    • Add-On Toxic Elements ( Metabolomix+):  $57

    • Add-On Vitamin D (For NutrEval):  $57

    • Add-On Essential and Metabolic Fatty Acids (Blood Spot) (For Metabolomix+ only):  $57


COACHING

COACH

Lara Morales Diatter, Relationship Coach

COACHING RATES

Relationship Coaching Package

  • 10 Session Relationship Coaching Package: $2,250 upfront 
    Includes: 10 60-min Coaching Sessions that focus on building resilient relationships

DISCLAIMER

This Good Faith Estimate shows the costs of items and services that are reasonably expected based on your health care needs. The estimate is based on information known at the time the estimate was created. It 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. 

This Good Faith Estimate is not a contract and does not require you to obtain the services or items from the providers or facility identified in it. You have the right to request another Good Faith Estimate at any time during your course of care.