Good Faith Estimate
You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost
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. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.
How this applies to this practice
Dr. Carlson is an out-of-network provider. If you are not using insurance to pay for your care, you are entitled to a Good Faith Estimate before services begin. You will receive one in writing as part of your intake paperwork, and you may request one at any time before scheduling.
Psychotherapy is ongoing rather than a single procedure, so an estimate covers an expected course of care over a defined period. The estimate is based on the information known at the time it is written. It is not a bill, and it is not a contract. How long therapy continues is decided together and reviewed regularly, so the actual total may be higher or lower than the estimate.
Current fees
- Individual
- $250 per 50-minute session
- Couples
- $325 per 50-minute session
- Couples, 90 min
- $450 per 90-minute session
- Couples intake
- Couples begin with a 90-minute intake session
- Intensives
- By inquiry — depends on format and length
- Workshops
- By inquiry — depends on format and length
A monthly superbill is provided for you to submit to your insurer for possible out-of-network reimbursement. A small number of reduced-fee hours are reserved each year; if cost is a barrier, say so on the consultation call.
Provider information
- Provider
- Marianne Carlson, PsyD
- License
- Licensed Psychologist, State of Texas, License #38750
- NPI
- 1003584665
- Location
- 2828 Buffalo Terrace, Houston, TX 77019
- Contact
- marianne@drmariannecarlson.com
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, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.
Dispute process
If you are billed for more than this Good Faith Estimate, you may 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.
The provider or facility cannot move the bill for the disputed item or service into collection or threaten to do so, or if the bill has already moved into collection, must cease collection efforts. The provider or facility must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility cannot take or threaten to take any retributive action against you for disputing your bill.
There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity agrees with you, you will pay the Good Faith Estimate price, reduced by the $25 fee. If the SDR entity disagrees, you will pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.
Keep a copy of your Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
Privacy Act statement
CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). The information may be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity's compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.
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