Good Faith Estimate

Right to Receive a Good Faith Estimate of Expected Charges – Under the “No Surprises Act”

Dr. Monica Ellis-Blied (Psy30328)

Clinical Psychologist & Founder 250 West 1st Street Suite 214

Claremont, CA 91711 (909) 741-2849


Listed below are the services offered at Dr. Blied – Faces of Health – A Psychological Corporation, along with estimated rates, except when otherwise agreed upon with Dr. Blied:

·      15-minute Consultation for new clients: no cost

·      Intake Appointments: $240 [service code 90791]

·      Individual Therapy (45-52 min): $220/session [service code 90834 or 90837]

·      Individual Therapy (60 min): $240/session [service code 90837]

·      Couple’s Therapy (45-52min): $240/session [service code 90837 or 90847]

·      Couple’s Therapy (60min): $280/session [service code 90837 or 90847]

·      Individual or Couples Therapy (90min): $350/session [service code 90837 or 90847]

·      Group Therapy (75min): $65/session [service code 90853]

·      ADHD (only) Assessments: $3900 [service codes 96116, 96130, etc.]

·      Autism + ADHD Assessments: $4800 [service codes 96116, 96130, etc.]

·      Accommodations/Comprehensive Assessments: $7000-$8000, depending on the client’s needs and referral question [service codes 96116, 96130, etc.]

·      Administrative Fees (for completing any letters or forms): $60/15 minutes ($60 minimum)

·      Fees for participating in any legal matter: $540/hour plus travel time (due in advance). Appearances at court or litigation require a 10-hour advanced payment per day ($5400/day).

Diagnosis codes are unique to each client and not listed above. The fees above are listed in your consent forms, which you signed when we first began treatment together (some rate changes may apply).


There is no pre-determined timeline for how long you will be in therapy. Dr. Blied provides long-term and trauma-focused treatments, along with integrative treatments that are individualized to best serve the needs of each client (these include: cognitive behavioral therapy, acceptance and commitment therapy, vagus nerve stimulation training, biofeedback therapy, mind-body health connection education, mindfulness training, psychodynamic processing, emotion-focused therapy, eye-movement desensitization and reprocessing (EMDR) therapy, Brainspotting, motivational interviewing, and cognitive processing therapy, among other modalities). The late-cancellation or late appointment change fee (less than 24 hours-notice) is equivalent to a full session fee, and is not covered by insurance.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

·      Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

·      You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

·      Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

·      If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.


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 good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate. 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. There may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. The information provided in the good faith estimate is only an estimate and that actual items, services, or charges may differ from the good faith estimate.

If you are billed substantially more than this Good Faith Estimate (at least $400 more than expected), 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 For questions or more information about your right to a Good Faith Estimate or the dispute process, visit