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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, PHD, APCC:

  • 60-Minute Individual Psychotherapy (CPT Code: 90837): $150.00; 
  • 90-Minute Family Psychotherapy (CPT Code: 90847): $225


Charlotte Molali, LCSW: 

  • 60-Minute Individual Psychotherapy (CPT Code: 90837): $150.00; 
  • 90-Minute Family Psychotherapy (CPT Code: 90847): $225


Cristina Haro, MA, AMFT:

  • 60-Minute Individual Psychotherapy (CPT Code: 90837): $150.00; 
  • 90-Minute Family Psychotherapy (CPT Code: 90847): $225


Leslie May, AMFT:

  • 60-Minute Individual Psychotherapy (CPT Code: 90837): $150.00; 
  • 90-Minute Family Psychotherapy (CPT Code: 90847): $225


Francis Toal, APCC:

  • 60-Minute Individual Psychotherapy (CPT Code: 90837): $150.00; 
  • 90-Minute Family Psychotherapy (CPT Code: 90847): $225


Shade Pinkins, ASW:

  • 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= $___________


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, 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.


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.

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Healthy Minds Counseling Center

191 Sand Creek Road, Suite 230, Brentwood, CA 94513

Phone: (925) 663-8158; Fax: (925) 644-6145

Kira Monterrey, LCSW, MPA

Founder/Owner/Therapist

CA License #LCSW81553

Copyright © 2024 Kira Monterrey - All Rights Reserved.


A Woman Veteran Owned Business

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