Good Faith Estimate

In compliance with the No Surprises Act (H.R. 133), all health care providers, facilities, health plans, and insurers are required to provide patients with a Good Faith Estimate prior to services being rendered. This allows uninsured or self-pay individuals to have access to information about health care pricing before receiving care.

Provider name and credentials: Jacqueline Sasso, MMFT, LMFT-A
License: SC 7940
NPI: 1225789589
EIN: 93-1395648
The services provided by Jacqueline Sasso at Jacqueline Sasso Therapy Services, LLC include
the following:
Individual therapy
Couples therapy
Family therapy

Common service and service codes used at Jacqueline Sasso Therapy Services, LLC
include:
90791: Initial Intake Assessment
90837: 55-minute individual session
90834: 45-minute session
90847: 75-minute couples or family therapy session
Common diagnostic codes used at Jacqueline Sasso Therapy Services, LLC:
F43.20 Adjustment Disorder, Unspecified
Z63.0 Relationship Distress with Spouse or Intimate Partner
Z62.89 Phase of Life Problem
Z91.49 Other Personal History of Psychological Trauma

A note about diagnosis:
At Jacqueline Sasso Therapy Services, LLC, I do not typically diagnose clients unless I believe a specific diagnosis to be accurate after evaluation and, after consultation with the client, I believe that having a mental health diagnosis is likely in the client's best interest. Instead of using diagnostic codes, I typically use Z codes, which represent general areas of concern to be addressed in therapy. Please speak to your therapist about this practice if you have any questions or concerns.

Where services will be rendered:
In-person at Five Forks Counseling Group, LLP
Online through a secure, HIPAA-compliant video-based platform

At Jacqueline Sasso Therapy Services, LLC, I recognize that every client's therapy journey is unique. How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including:

Your schedule and life circumstances
Your therapist's availability
Ongoing life challenges
The nature of your specific challenges and how you address them

I recognize that not all clients will meet with their therapist on a weekly basis. Each individual who receives services at Jacqueline Sasso Therapy Services, LLC has the ability to determine, along with their therapist, the frequency of sessions that are most clinically appropriate for their situation.

You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your treatment goals and your therapy journey is complete.

For Individuals, Couples, & Families

The rates for individual, couples, and family therapy at Jacqueline Sasso Therapy Services, LLC is as follows:
75-minute intake appointment: $185
55-minute session: $185
30-minute session add-on: $92

Disclaimers

This Good Faith Estimate is not a contract and does not require you to obtain the items or services from Jacqueline Sasso at Jacqueline Sasso Therapy Services, LLC. Additionally, the information provided in this good faith estimate is only an estimate. Actual items, services, or charges may differ from the Good Faith Estimate.

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.

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 (appeal) the bill.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may 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 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.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 368-1019.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.