Good Faith Estimate of Client Costs
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
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:
Description of Services Provided:
Counseling and/or psychotherapy as indicated on an approximately weekly basis.
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.