Coping Resource Center

Good Faith Estimate

Provider Estimate

Provider name: The Coping Resource Center Provider/facility type: Private Practice

Street address: 2211 Norfolk Street, Suite 455 City: Houston

State: Texas

ZIP code: 77027

Contact person: Jazzie Johnson

Phone: 832-304-0207 (tel:832-304-0207)

Email: admin@drlizross.com

Taxpayer Identification Number (EIN): [84-1782641]

Details of Services and Items for the Coping Resource Center

Service/item: Psychotherapy

Address where service/item will be provided

2211 Norfolk Street, Suite 455, Houston Texas 77098 Diagnosis code: F43. 23

Service code: 90834

Quantity: 4-30

Expected cost per clinician:

-Elizabeth Ross, PhD: $250 per session

-Danielle Carr, PhD: $250 per session

-Abigail Candelari, PhD: $250 per session

 

-Couples Counseling: $300 per session

-Family Counseling: $300 per session

 

Supervised Clinician:

-Sam Leonard, M.A.: $150 per session

-Emily Young, B.S., CTRS: $150 per session

 

Range of Total Expected Charges for all future psychotherapy sessions from The Coping Resource Center.: $600-$9,000.

Additional health care provider/facility notes: It is challenging to provide a good faith estimate for services before an initial evaluation. The number of psychotherapy sessions can vary depending on clinical presentation, the pace of treatment, and

client preferences.

If at any time either party wishes to discontinue services, the client is NOT liable for charges associated with services not rendered. The client and clinician are in no way beholden to commit to any number of sessions before, or during the initiation of therapy.

Disclaimer

This Good Faith Estimate shows the costs of items and services that are reasonably expected based on your health care needs. The estimate is based on information known at the time the estimate was created. It 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 HHS at (800) 368-1019 (tel:(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 (tel:(800) 368-1019).

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.