Good Faith Estimate
Disclaimer
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 (231)714-4840.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or (800) 368-1019.
Services and Fees
Provider Name: Santhi Periasamy, Ph.D.
License #: 33429 Texas
Provider Mailing Address: 3303 Louisiana St., Ste. 200, Houston, TX 77006 or Telemental Health
Provider Service Addresses: 3303 Louisiana St., Ste. 200, Houston, TX 77006 or Telemental Health
Provider/Facility Type: Licensed Psychologist; Independent Practice; Out of Network
Provider Phone #: (713) 942-7793
Provider Tax ID#: 026-66-1676
Provider NPI #: 1053606517
Details of Services and Items
Service: Psychotherapy Services
Address where service will be provided: Via Telemental Health, or in-person 3303 Louisiana St. Ste. 200, Houston, TX 77006
Service Code(s):
90791 Diagnostic Interview
90834; 50- minute therapy appointment
90837; 60-80 -minute therapy appointment
90847; Conjoint therapy
Quantity
Your therapist will collaborate with you throughout your treatment to determine what length and how many sessions and/or services you may need to receive the greatest benefit based on your diagnosis(es) or presenting clinical concerns.
Expected Cost
This Good Faith Estimate explains your therapist’s rate for each service provided. Please note the expected cost is based on the fee times the number of sessions needed as determined in collaboration with your therapist.
Total Expected Charges from Santhi Periasamy, Ph.D.:
Please view Rates on Website and clinical documentation in the client portal to identify current rates per service.
Additional Health Care Provider/Facility Notes:
All Services provided out-of-network; Client may file for self-reimbursement.
*Please note that Place of Service (In-person vs. Telemental health) is not delineated above since the charges are identical.
Conclusion
You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided per session.
Your total cost of services will depend upon the number and length of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not oblige you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.
This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
The fee for a 50-minute psychotherapy appointment (in-person or via telehealth) is $200. The fee for an 80-minute psychotherapy appointment is $300. The fee for a 50-minute conjoint psychotherapy appointment is $280.00 and an 80-minute appointment is $320.00. Appointments of other lengths (e.g. 30, 75, or 90 minutes) may be scheduled at client and therapist discretion and fees are proportional to length of time reserved.
Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs.
You have a right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).
You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.