Good Faith Estimate of Client Costs 

Provider Information 

Name: Iris M Hogan, MSW, LICSW 
Address: 1417 NW 54th Street, Suite 223, Seattle, WA 98107 
National Provider Identifier (NPI): 1255747978 
Taxpayer Identification Number (TIN): 218-13-9670 
Patient Information: 
Patient Name:
 Date of Birth: 

Estimated Cost of Services Provided 

Each 53 minute in Psychotherapy Session is $190 
Diagnosis (when applicable): 
I am not able to propose an appropriate diagnosis or course of treatment for you until we have spent some time together. As soon as I am able to identify a diagnosis and an appropriate course of treatment, I will discuss it with you. Your diagnosis, if any, will have no impact on the amount you are billed. 

Estimated Duration of Recurring Services under this Estimate: 

Maximum 12 months: 
6 months 

Description of Services Provided: 

Counseling and/or psychotherapy as indicated on an approximately weekly basis. 

Important Disclosures: 

Services are anticipated to be provided generally on a weekly basis until treatment is terminated. Additional services may be recommended. This estimate of your costs is only an estimate, and your actual charges may differ. You have the right to initiate the patient-provider dispute resolution process if the charges you are actual billed substantially exceed the expected charges in this estimate. You may contact me directly if the billed charges are higher than this Good Faith Estimate,  or you can directly 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, that will not adversely affect the quality of health care services I provide to you. 

This estimate of costs is not a contract and does not obligate you to obtain clinical services from me.