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

GOOD FAITH ESTIMATE OF CHARGES FOR THE CONNECTIVE - BENICIA, CA

PROVIDER FACILITY

The Connective
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 , 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)

  • Hannah Smith, Registered Associate MFT #143931 (NPI #1063209690) I Supervised by: Nicole Desamparo, LMFT #48275 (NPI # 1396896213)

  • Marika Yakumithis, LMFT #156448 & Registered Associate PCC #13481 (NPI #1750911079 ) I Supervised by: Nicole Desamparo, LMFT #48275 (NPI # 1396896213)

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

RATES

Diagnostic Intake/Initial Session: 

  • 90791 Diagnostic Intake/Evaluation (60-90 minute sessions): $240 - $370*

Follow-up Therapy Sessions (Fee is per Session)

  • 90832 Psychotherapy 25 minute check-in session: $120

  • 90834 Psychotherapy 45 minute session: $185

  • 90837 Psychotherapy 60 minute session:  $240  

  • 90837 Psychotherapy 75 minute session:  $305

  • 90837 Psychotherapy 90 minute session:  $370

  • 90847 Family + Couples Psychotherapy w/ client present: $240 - $370*

  • 90846 Family + Couples Psychotherapy w/o client present: $240 - $370*

  • No-show or Late Cancellation (less than 48-hours notice): $120 - $370* 

  • 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. 

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.

Should there be any fees for services not listed in this document, you will receive a supplemental document outlining those services and their associated fees

By continuing to book and attend services with your Connective practitioner, you are acknowledging that you have been notified of these fees and estimates in good faith. You further acknowledge that this is only an estimate and actual charges may differ. You, as the patient, have the right to initiate the patient-provider dispute resolution process if the actual bill charges substantially exceed the expected charges provided in the good faith estimate.

This GFE expires at the end of day on 12/31/2025 and will be renewed annually while you remain an active client at The Connective.