Good Faith Estimate

Provider Estimates:
Kira Monterrey, LCSW: 60-Minute Individual Psychotherapy (CPT Code: 90837): $150.00; 90-Minute Family Psychotherapy (CPT Code: 90847): $225

Marie Whelan, APCC, 60-Minute Individual Psychotherapy (CPT Code: 90837): $150.00; 90-Minute Family Psychotherapy (CPT Code: 90847): $225

Melinda Pollack, AMFT: 60-Minute Individual Psychotherapy (CPT Code: 90837): $150.00; 90-Minute Family Psychotherapy (CPT Code: 90847): $225

Charlotte Santos, ACSW: 60-Minute Individual Psychotherapy (CPT Code: 90837): $150.00; 90-Minute Family Psychotherapy (CPT Code: 90847): $225

Mabel Paz, AMFT: 60-Minute Individual Psychotherapy (CPT Code: 90837): $150.00; 90-Minute Family Psychotherapy (CPT Code: 90847): $225

Jamilia Fields, MD: Psychiatric Diagnostic Evaluation with Medical (CPT Code: 90792): $450.00; Level 4 office visit (CPT Code: 99214): $250.00

All Clinicians: Fee for writing professional letter: $100.00

All Clinicians: Fee for late cancel or no-show: 100% session fee.

Provider name: Kira Monterrey, LCSW; Melinda Pollack, AMFT; Charlotte Santos, ACSW; Mabel Paz, AMFT, or Jamilia Fields, MD.
Provider/facility type: Healthy Minds Counseling Center
Street address: 1120 2nd St. STE C
City: Brentwood
State: CA
ZIP code: 94513
Contact person: Kira Monterrey, LCSW
Phone: (925) 852-3987
Email: kira@healthymindscenter.com
National Provider Identifier (NPI): 1629469085
Taxpayer Identification Number (TIN): 83-2530317

Total Expected charges for facility/ Services:
Multiply session rate by number of sessions to achieve total expected charges= $___________

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, federal law allows you to dispute (appeal) 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.

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.

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.