Fees

• Adults -Individual Therapy $170
• Specialty Treatment: Brainspotting $180
• Family Therapy $180

• Hardship $1,100
• U-Visa/T-Visa $900
• VAWA $900
• Asylum $900
  • 7 business days turn around $300
  • 3 business days turn around $500

Aetna Insurance

Superbills for out of network members

No Surprises Act: Good Faith Estimate 

Name:   DOB:    

Address:   Apt #: 

City:  State: CA Zip Code: 

Patient Diagnosis:____________________________

Date of good faith estimate:_______________________

Good Faith Estimate Introduction:

Effective January 1, 2022 health care providers are required to give uninsured patients a “Good Faith Estimate” (GFE) which is an estimate of the costs for services offered. Patients may receive this GFE when scheduling for services or by request of the patient(s). This legal requirement is part of legislation enacted in December 2020 and is part of the “No Surprises Act.” This legal requirement seeks to protect patients from “surprise” billing. This means that you have the right to receive a “Good Faith Estimate” explaining how much your health care will cost.

As of December 31, 2020, this applies to you if,:
• You are uninsured and/or self-pay and
• You have any kind of health insurance coverage and intend to submit a claim to that insurance for the services you receive.

If you are uninsured and/or self-pay you may request a Good Faith Estimate of expected charges: in clear, understandable written documentation; orally when services are scheduled or when asking about costs; and in accessible formats for the language you speak.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.

Provider Information:

Provider name: Sandra Ascencio, LCSW
Provider/facility type: Mental Health Services
Street address: 491 S. Marengo Ave
City: Pasadena
State: CA
ZIP code: 91101

Contact person:
Phone:
Email:
National Provider Identifier (NPI):
Taxpayer Identification Number (TIN):

Common Services and Service Codes used at Sandra Ascencio, LCSW:

90791: Therapy Intake/Psychodiagnostics Session
90834: Individual Psychotherapy Session with patient (Duration: 45-50 minutes)
90837: Individual Psychotherapy Session with patient (Duration: 60 minutes)
90847: Couple/Family Psychotherapy Session with patient
90853: Group Psychotherapy Session

Common Diagnosis Codes used at Sandra Ascencio, LCSW:

• F43.10 (Post-Traumatic Stress Disorder)
• F32.9 (Major Depressive Disorder)
• F31.— (Bipolar Disorder)
• F41.1 (Generalized Anxiety Disorder)
• F41.9 (Anxiety Disorder, Unspecified)
• Z63.0 (Relationship Distress with Spouse or Intimate Partner)
• F43.20 (Adjustment Disorder, Unspecified)
• Z63. 4 (Bereavement (Uncomplicated))
• R69 (Diagnosis Deferred)

If your insurance plan allows for partial reimbursement of your out of network mental health services that Sandra Ascencio, LCSW, provides you and you wish to submit a Superbill for such reimbursement, your therapist will provide you a specific diagnosis once they have worked with you long enough to be able to accurately do so.

Understanding Service Codes & This Good Faith Estimate:

At Sandra Ascencio, LCSW, we provide therapy that typically lasts approximately 50 minutes. This depends on the information being processed with the patient, patient need, and therapist assessment. There may be instances where the duration of the session lasts longer than 50 minutes or, in rare instances, less than 50 minutes. Again, this is based upon clinical need of the patient. The diagnostic code will be applied for the individual, couple, and/or family to match the type (intake, individual or couple/family) and amount of time (duration) of each therapy session.

Understanding Time & This Good Faith Estimate:

Each individual’s experience and journey with their mental health is unique and the therapy process is highly personal. The frequency (how many times per week) and amount of time in each session for each patient, couple, or family is unique to their particular circumstance. The frequency, time of each session, and duration of the therapy relationship is influenced by many factors, including (but not limited to) the patient, couple, and/or family’s specific engagement with the therapy process, their life history and experiences prior to coming to therapy, and their experiences while in therapy. Therapy attendance, frequency, time, and duration are also influenced by:
• Your schedule
• Your family requirements/responsibilities
• Ongoing life challenges
• The specific challenges that have led an individual, couple, and/or family to therapy
• How an individual, couple, and/or family addresses their unique challenges
• Your therapist’s schedule/availability

Due to the many factors that can impact therapy you and your therapist will continually assess the frequency, time, and duration of your therapy appointments as well as your therapy goals and need for termination of therapy.

Understanding Diagnosis & This Good Faith Estimate:

At Sandra Ascencio, LCSW, patients are typically diagnosed based upon their reported experiences in clinical interview and response to questionnaires and assessment materials. For diagnostic accuracy, therapists will consult with the patient, other professionals, and/or completed documentation. However, as information about a patient’s experiences with their mental health symptoms evolve, their diagnosis may change. As a result, there is no price difference based upon psychological diagnosis. Instead, price differences are based upon the type and duration of service received. Your therapist will further discuss diagnosis with you as part of your therapeutic care.

Good Faith Estimate for Health Care Services

Below you will see the Good Faith Estimate (GFE) provided by Sandra Ascencio, LCSW. This GFE includes the total cost of weekly therapy for one year (52 weeks) with your therapist. This GFE for 52 weeks of therapy would mean that therapy would occur for each week of the year without skipping any weeks at the current rates of Sandra Ascencio, LCSW,. This 52-week year estimate is used to provide the most gracious estimate of one full year of therapy, with several exceptions noted below in the disclaimer.

The current full rate for psychotherapy services with Sandra Ascencio, LCSWare:

- 50 minute session:
- 90 minute session: 

This means that if you meet with your therapist once per week for one year (52 weeks), at the prices listed above, the total cost for one year (52 weeks) would be:
 

- $_____ x 52 = $___________ (50-minute session)
- $______ x 52= $___________ (90-minute session)

The above estimated costs are valid for 12 months from the date of the Good Faith Estimate.

Additional or Emergency Sessions (any extra sessions requested during the year, outside of regular schedule currently agreed upon): each additional or emergency sessions will be charged at the rate of your current fee.

If rates increase or additional services not referenced in this document are needed, a new Good Faith Estimate will be provided. Otherwise, this Good Faith Estimate will remain current until such changes occur.

Understanding Payment & This Good Faith Estimate:

At Sandra Ascencio, LCSW, you are financially responsible for the full price of the services you receive. You will be expected to pay for each session at the time it is held, unless we agree otherwise in advance. Payment schedules for other professional services (e.g. required legal involvement) will be agreed upon when they are requested. For further information about billing and payment, please reference your Informed Consent for Psychotherapy & Practice Policies document provided to you via e-mail and/or secure access through the Client Portal.

Disclaimer

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs. The estimate is based on information known at the time the estimate was created. As this is an estimate, it is possible that the actual items, services, or charges may differ from the provided Good Faith 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, crises, or special circumstances occur, including but not limited to the fee associated with no-show and late cancellation of appointments (as outlined in the previously mentioned Informed Consent for Psychotherapy & Practice Policies document provided for you via e-mail and/or secure access through the Client Portal).

The Good Faith Estimate is not a contract and does not require uninsured and/or self-pay individuals to obtain the noted services from Sandra Ascencio, LCSW, You have the right to terminate therapeutic services with your therapist and/or Sandra Ascencio, LCSW, at any time without any legal or financial obligations other than those already accrued.

If this Good Faith Estimate is at least $400 less than the actual total costs of the services you receive, 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.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can 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, as billed.

To learn more and get a form to start the dispute (appeal) process, to receive answers to your questions, and attain more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800.985-3059.

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.

Signature 

Date