GFE

You are entitled to a Good Faith Estimate that shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. This estimate is based on the information that is known at the time this estimate is prepared. 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 $400 more (per provider) than this Good Faith Estimate (GFE), you have the right to dispute the bill. You may contact Theresia Paauwe, LMHC, if the billed charges are at least $400 higher than the GFE. You can ask 180 Counseling, LLC to update the bill to match the GFE, 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 GFE. 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 CMS at 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 or call CMS at 1-800-985-3059.

This GFE is not a contract. It does not obligate you to accept the services listed. Keep a copy of this Good Faith Estimate (GFE) in a safe place or take pictures of it. You may need it if you are billed more than $400 than the estimate provided.

This estimate is for psychotherapy services.

Brief explanation of estimate for new patients:

The estimate below is the range of costs that is likely for most new patients. Until an initial evaluation is completed and therapy begins, a clear picture of a client's specific diagnosis, issues and needs will be unknown. Therapy patients may choose to be seen for weekly, bi-weekly, or monthly standard sessions, as agreed upon by the patient and the therapist. They may also elect to schedule extended (90 or 120 minute) sessions. 

Below is an estimate for one year of counseling services based on the number of visits scheduled at the standard hourly rate for 180 Counseling:

• Weekly session at $140 per 60 minute session x 52 weeks = $7,280
• Bi weekly Sessions at $140 per 60 minute session x 26 weeks = $3,6480
• Monthly Sessions at $140 per 60 minute session x 12 months = $1,680

In some cases, a patient’s issues may be more complicated, so additional sessions may be needed during the time covered by this estimate.

Additionally: 

• Late cancel (less than 24 hours notice)/No Show fee is charged at the full session rate 
• 90 minute sessions are $200
• 120 minute sessions are $270

The following is a detailed list of expected typical charges for psychotherapy services scheduled in one year:

Service                     Diagnosis                      Service            Quantity            Cost               Expected 

                                    Code                              Code                                             Per Unit        Cost

Initial Intake              90791                 To be determined      1 session              $140                 $140

Psychotherapy         90837                 To be determined     12-52 sessions      $140         $1,680-7,280

Office from which services are provided: 180 Counseling, LLC.

Address: 14074 Trade Center Drive, Suite 115 

City, State, Zip: Fishers, IN 46038

Tax ID Number: 88-3582735

NPI Number: 1174220982

Contact: Theresia M Paauwe, LMHC, Owner 

Phone: (317) 207-2253 

Email: at Theresia@180counsel.com or INFO@180Counsel.com