Effective January 1, 2022, a ruling went into effect called the "No Surprises Act" which requires practitioners to provide a "Good Faith Estimate" in regard to out-of-network care. The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your health care needs for an item or service, a diagnosis, and a reason for therapy. 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 and will be provided a new "Good Faith Estimate" as requested should this occur. If this happens, federal law allows you to dispute (appeal) the invoice if you and your therapist have not previously talked about the change and you have not been given a good faith estimate.

Under Section 2799B-6 of the Public Health Service Act (PHSA), health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request, or at the time of scheduling health care items and services to receive a "Good Faith Estimate" of expected charges. Note: The PHSA and GFE does not currently apply to any clients who are using insurance benefits, including "out of network benefits'' (i.e., submitting super bill s to insurance for reimbursement).

Timeline requirements: Practitioners are required to provide a good faith estimate of expected charges for a scheduled or requested service, including items or services that are reasonably expected to be provided in conjunction with such scheduled or requested item or service. That estimate must be provided within specified timeframes:

• If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling;

● If the service is scheduled at least 10 business days before the appointment date, no later than three business days after the date of scheduling;

● If the uninsured or self-pay patient requests a good faith estimate (without scheduling the service), no later than three business days after the date of the request.

This agreement has been drafted in order to clarify how this process works at Integrative Therapy PLLC what you can expect during this process, and to avoid misunderstanding in accordance with the No Surprise Act. Cash pay clients are described as individuals with no insurance and seeking therapy independently, are enrolled in an insurance plan but are not wanting to have claims submitted (opting out of insurance) and/or the provider is not in-network and the client opts to receive services from them.

As a means to provide full transparency, Integrative Therapy PLLC has outlined a list of all of our providers and their accepted in-network insurances and cash rates at this time:

• Courtney Morris, MS, LPC-Associate – Cash pay

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. 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.

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.

It should be noted that treatment is evaluated every 90 days, which may impact this estimate as frequency of care may change. Integrative Therapy PLLC recognizes every client's treatment is unique. How long you need to engage in therapy and how often you attend sessions will be influenced by several factors including:

● Ongoing Life Transitions 

● Your schedule and life circumstances

● Therapist availability

● Crisis or Unexpected responses needed

● The nature of your specific treatment goals and how you choose to address them

● Personal finances

You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new "Good Faith Estimate" will be issued should your frequency or needs change.

Common Services at Integrative Therapy PLLC:

● 90791: Initial therapy intake

● +90785 Interactive Complexity Add-on (intake)

● 90837: Ongoing therapy appointments

● 90839: Therapy Session-Crisis

● +90785 Interactive Complexity add-on (sessions)

● 90847- Family Therapy with Client Present 

● 90846- Family Therapy with Out Client Present

● Reiki Sessions/Meditation Sessions/Breathwork Sessions

Additional Fees Rates:

Fees are reviewed each year and may increase periodically. Every consideration to the Client’s current finances will be made. Any increase will be discussed with Client and a 30-day notice will be given prior to fee increase. Please understand you have the right to terminate therapy at any point.

Integrative Therapy PLLC is committed to providing caring and professional mental health services to all our clients. As part of the delivery of mental health services we have established a financial policy, which provides payment policies and options to all consumers. The financial policy of the clinic is designed to clarify the payment policies as determined by management of Integrative Therapy PLLC.

Current fees are as follows:

Joanna Trevino, MA, LPC-S

• Intake sessions - $175 per 60 min session

• Individual sessions - $175 per 60 min session or $262.50 for 90-minute sessions; or $300 for 120-minute sessions.

• Reiki Sessions/Meditation Sessions billed at $175 per 60 min session or $262.50 for 90-minute sessions; or $300 for 120-minute sessions.

• Any time spent in session over one hour will be billed at 15 min increments of $43.75

• If Therapist is needed to testify in court a fee of $3,500 per day – paid prior to appearance – is required.

• Credit cards charged via Square carry a processing fee of 3.75% plus .15

• Completing paper work / Documentation for Patient

o Billed at $175 per hour with a minimum of one hour

 Any time over one hour will be billed in 15 min increments of $43.75

• If you request printed documents from Mind-Body Counseling & Training Center

o $50 fee for first 50 pages

o $0.25 per page thereafter

o $25 fee assessed for having documents delivered by certified mail.

Any time outside session spent answering extensive emails or responding to requests for contact outside of session time will be billed in 15-minute increments at $43.75 per increment. Any fees incurred from additional time spent with client will be due at time services rendered. 

You, the client, are responsible for the cost of any technology at your location, such as a computer, device, phone, phone call charges, software, and headset.

Your provider will require a credit card number to be placed on file, to obtain fees in the case of no payment, no shows, or cancelling within the 48-hour timeframe. It is your responsibility to keep your card on file up to date and notify your therapist if you will not be able to make your scheduled session.

Current fees are as follows:

Courtney Morris, MS, LPC-Associate and Adriana Canales, MS, LPC-Associate

• Intake sessions - $125 per 60 min session

• Individual sessions - $125 per 60 min session or $187.50 for 90-minute sessions; or $250 for 120-minute sessions.

• Reiki Sessions/Meditation Sessions/Breathwork Sessions are billed at $125 per 60 min session or $187.50 for 90-minute sessions; or $250 for 120-minute sessions.

• Any time spent in session over one hour will be billed at 15 min increments of $31.25

• If Therapist is needed to testify in court a fee of $3,500 per day – paid prior to appearance – is required.

• Credit cards charged via Square carry a processing fee of 3.75% plus .15

• Completing paper work / Documentation for Patient

o Billed at $175 per hour with a minimum of one hour for supervision provided by Joanna Trevino, MA, LPC-S in addition to $125 per hour for LC-Associate

 Any time over one hour will be billed in 15 min increments of $21.25

• If you request printed documents from Integrative Therapy PLLC

o $50 fee for first 50 pages

o $0.25 per page thereafter

o $25 fee assessed for having documents delivered by certified mail.

Any time outside session spent answering extensive emails or responding to requests for contact outside of session time will be billed in 15-minute increments at $21.25 per increment. Any fees incurred from additional time spent with client will be due at time services rendered. 

You, the client, are responsible for the cost of any technology at your location, such as a computer, device, phone, phone call charges, software, and headset.

Your provider will require a credit card number to be placed on file, to obtain fees in the case of no payment, no shows, or cancelling within the 48-hour timeframe. It is your responsibility to keep your card on file up to date and notify your therapist if you will not be able to make your scheduled session.

The receipt of payment / Invoice may also be used as a statement for insurance if applicable to you. There is a $50 fee for any returned checks, after one returned check, check payments will no longer be accepted. If you pay by credit card you may receive a receipt via email, and it will likely show up on your billing statement.

These fees are reviewed annually, and an increase may be applied to our, an updated Notice will be sent at that time. 

Your Good Faith Estimate Diagnosis:

At Integrative Therapy PLLC, we work towards decolonizing mental health, which includes working towards a more client-centered, strengths-based, ethical and inclusive practice. Integrative Therapy PLLC must diagnose all clients per the requirements of the "No Surprises Act". This diagnosis is only to satisfy the federal requirement for this form. This is not a formal psychological diagnosis. A formal diagnosis occurs after an assessment has been completed and is individual to each client. Your diagnosis will take place 1-5 sessions after beginning treatment and will be reviewed with you as we begin treatment planning. It is within your rights to decline a diagnosis per state and federal guidelines.

Primary Diagnosis: Z73.3 - Stress Not Elsewhere Specified

Secondary Diagnosis: F99 - Mental Health Disorder, Not Otherwise Specified

Provider Information:

Provider: Joanna Trevino, MA, LPC-S

Texas License # 66771

Provider: Courtney Morris, MS, LPC-Associate

Texas License # 86726

14526 Jones Maltsberger Road, Suite 209 - San Antonio TX. 78247

Tel: 210-219-4302 

Email: joannatrevinolpc@gmail.com

NPI# 1790046423

EIN # 460652340

Your Financial Responsibility Summary

Joanna Trevino, MA, LPC-S:

Therapy fees per session: $175- 60 minute session 

Good Faith Annual estimate: $9,100.00

• This is the amount you would owe if you were to attend therapy for 52 sessions in a year (weekly, without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc.). The "Good Faith Estimate" requires practitioners to provide an exact estimate and does not allow for a range. Out of an abundance of caution and transparency, we will only quote weekly appointments. Your session frequency is unique and individualized. It may be less than 52 weekly sessions, and you may have a variety of lengths of sessions (ex: 60 minutes; 90 minutes; 120 minutes) per clinical/therapeutic appropriateness. 

Courtney Morris, MS, LPC-Associate:

Therapy fees per session: $125- 60 minute session 

Good Faith Annual estimate: $6,500

• This is the amount you would owe if you were to attend therapy for 52 sessions in a year (weekly, without skipping any weeks for holidays, break, vacation, unplanned events/sickness, etc.). The "Good Faith Estimate" requires practitioners to provide an exact estimate and does not allow for a range. Out of an abundance of caution and transparency, we will only quote weekly appointments. Your session frequency is unique and individualized. It may be less than 52 weekly sessions, and you may have a variety of lengths of sessions (ex: 60 minutes; 90 minutes; 120 minutes) per clinical/therapeutic appropriateness.