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Good Faith Estimate for Health Care Items and Services

Wentworth and Associates, P.C.
11111 Hall Road, Suite 303
Phone (586) 997-3153
Fax (586) 997-4956
Wentworth
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
* Date of Service
 
Wentworth and Associates
NPI 1306827191
Tax ID 38-3284673
* First Name
* Last Name
* Date of Birth
* Address
* City and State
* Zipcode
* Phone Number
Email Address
* Patient's Contact Preference
By Mail   By Email   By Cellphone/ Text  
The primary services at Wentworth and Associates are Psychotherapy.  The common billable codes and estimated fees are as follows:



        CPT Codes                                                                            Cost Per Session

           90791                                                                                          $212.00

           90832                                                                                         $91.00
           
           90834                                                                                         $121.00
 
           90837                                                                                         $179.00

           90846                                                                                        $148.00

           90847                                                                                         $120.00
           
           90792                                                                                         $200.00

           99213                                                                                           $90.00
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.
*This is only an estimate and actual services, and charges may differ
Separate estimates will be issued upon request for services that are in consideration of being provided by other Wentworth and Associates staff members. There may be other services required that must be scheduled separately during the course of treatment and are not included in the estimate.
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 (586) 469-7700 for the State of Michigan Department of Health and Human Services.
For questions or more information about your right to a Good Faith Estimate
and/or the dispute process, visit www.cms.gov/nosurprises or call (586) 469-7700 for the State of Michigan Department of Health and Human Services.
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.
By typing my name I am acknowledging that I have received the Good Faith Estimate from my therapist.  My therapist and I have discussed the potential charges and which procedure codes I can expect to be billed going forward.  I understand that my insurance is not in network with Wentworth and Associates and I can expect to be billed the out of network charges stated above.  

I understand that I can request a copy of this Good Faith Estimate at any time.
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