Viridian Counseling LLC  |  Good Faith Estimate

Good Faith Estimate

Notice of Expected Charges for Healthcare Items and Services

You have the right to receive a Good Faith Estimate explaining how much your healthcare will cost. Under the law, healthcare providers need to give patients who don't have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare items or services. 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 of your Good Faith Estimate. For questions or more information, visit www.cms.gov/nosurprises.

SECTION 1: PROVIDER INFORMATION

Provider Name: Sydney Dawson, MS, LPC, NCC

Practice Name: Viridian Counseling LLC

Address: 1 Prestige Drive, Suite 203F, Meriden, CT 06450

Phone: (475) 303-5281

Email: sydney@viridiancounselingllc.com

License: Licensed Professional Counselor (LPC), State of Connecticut

Individual NPI: 1790676138

Group NPI: 1467324228

EIN: 39-4228819

SECTION 2: FEE SCHEDULE

STANDARD SESSION RATES

•  Psychiatric Diagnostic Evaluation, 60 minutes (CPT 90791): $200.00

•  Individual Psychotherapy, 60 minutes (CPT 90837): $170.00

•  Individual Psychotherapy, 45 minutes (CPT 90834): $150.00

•  Individual Psychotherapy, 30 minutes (CPT 90832): $145.00

•  Couples/Family Psychotherapy, 60 minutes (CPT 90847): $170.00

SLIDING SCALE RATES

A limited sliding scale is available based on demonstrated financial need, determined on a client-by-client basis. Sliding scale availability is limited to 3 to 5 clients in active treatment at any time.

•  Full fee: $170.00

•  Mild financial strain: $150.00

•  Moderate financial strain: $130.00

•  Significant financial strain: $115.00

•  Highest need: $100.00

SECTION 3: PAYMENT POLICY

Full payment is due at the time of each session. Accepted payment methods include credit card, debit card, HSA/FSA card, check, or cash. A receipt will be provided for all payments received by hand, including check or cash. Balances over $100.00 must be resolved before additional sessions can be scheduled.

Superbills are available upon request for potential out-of-network insurance reimbursement. Viridian Counseling LLC does not bill insurance directly and is a cash pay practice.

SECTION 4: CANCELLATION AND NO-SHOW POLICY

Appointments must be cancelled at least 24 hours in advance to avoid a late cancellation fee. Clients may reschedule within the same calendar week as the original appointment to avoid this fee.

Late cancellations (less than 24 hours notice) and no-shows are subject to a fee of $100.00 each and will be documented in clinical records.

Clients with more than 3 late cancellations or no-shows within a 90-day period are subject to a discharge review. Clients who consistently fail to attend, respond to communication, or schedule follow-up appointments may be discharged for non-engagement. When appropriate, referrals to other providers will be offered.

Telehealth-specific: Clients participating in telehealth sessions must follow all procedures outlined in the Consent for Telehealth Agreement. Failure to meet telehealth requirements at the time of session may result in a late cancellation charge of $100.00 if the session cannot be rescheduled within the same calendar week.

SECTION 5: YOUR RIGHTS UNDER THE NO SURPRISES ACT

•  You have the right to receive this Good Faith Estimate in writing at least one business day before your scheduled service.

•  You may request a Good Faith Estimate before scheduling a service.

•  If you receive a bill at least $400 more than this estimate, you have the right to dispute that bill.

•  To dispute a bill, contact the U.S. Department of Health and Human Services at www.cms.gov/nosurprises or call 1-800-985-3059.

•  This estimate does not require you to obtain services from this provider.

•  This estimate does not include unknown or unforeseen costs that may arise during treatment.