Fee Agreement and Good Faith Estimate

No Surprises Act

In compliance with the No Surprises Act that went into effect January 1, 2022, all healthcare providers including psychiatrists and therapists are required to notify patients of their federal rights and protections against “surprise billing.” The purpose of the Act and of this document is to protect you from unexpected medical bills. 

This Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network psychiatrist or therapist (as we often are), if you are uninsured, or if you elect not to use your insurance. 

In case any of these situations apply to you, we are required to provide you with a “Good Faith Estimate” of the cost of services to you. Doing so is particularly challenging in mental health care because it is difficult to predict the length of treatment and because patients have a right to decide how long they want to participate. Therefore, we describe below the fees that typically apply for the types of services we offer, including for your condition. Going forward, we can collaborate on a regular basis to determine how many sessions you may need. 

Our pricing is also provided publicly on our website for simple and clear pricing for our patients to further prevent issues or confusion. See more here: forallmentalhealth.com/pricing

As per our terms and service agreements, all patients agree to pay the full rate unless otherwise negotiated before treatment begins or if in-network in which case they agree to pay their co-pay or co-insurance amounts and meet any necessary deductibles per their insurance plan. If you are a cash pay patient, payment will be billed to the credit card we have on file. After the initial consultation, regular follow-ups are scheduled depending on clinical needs. When you are seeing one of our providers and depending on your treatment plan and clinical discretion, the frequency of medication management appointments may vary accordingly. Note that these rates will remain in effect for at least a year from the start date of treatment and in the event of a fee increase after that time, a new Fee Agreement will be presented. 

FAMh For All Mental Health Psychiatric Telemedicine, LLC
4300 Biscayne Blvd Suite 203
Miami, Florida 33137

Base Rates and Fees

  • $199 / 60 minute initial visit

  • $99 / 20 minute follow-up visit

  • $75 / 15 minute patient refill only

  • $25 / per medical record request

  • $300 / hr (prorated per 15 minute increments @ $75) phone consultations outside of initial or follow up visits

  • $100 / per general form FAMh needs to fill out such as: documentation of treatment, animal support, employer treatment, and general treatment letters

  • $150 / Emotional Support Animal certification

  • New patients requesting state disability forms, life insurance forms, private insurance disability forms, and extended work absence or leave forms will require a $500.00 processing fee for the initial forms and $250.00 for the extension or subsequent forms. If you are an existing patient and your provider determines you will need disability / extended leave forms completed it will require a $250.00 processing fee for the initial forms and $125.00 for the extension or subsequent forms.

Please note the following:

  • Payment is required in full for each session if cash pay or your insurance co-payment at the time of your appointment. Currently, we only accept payments via credit or debit cards, Venmo, or Zelle. Please use our email: info@forallmentalhealth.com

  • These fees apply to all American Psychiatric Association DSM-5 diagnoses, corresponding ICD-10 and 90 codes. Additional codes could be used by your provider as deemed appropriate at the time of the visit.

  • We use diagnostic codes that are clinically accurate, but these do not guarantee reimbursement. 

  • Paperwork processing requires upfront payment. Submitting your portion of the completed form, including your signature, will expedite the paperwork process. Please note that insurance companies do not reimburse our providers for admin based tasks, so you are therefore responsible for the payment associated with processing any forms.

  • Kindly be aware that if you are on disability or leave, you will be required to have weekly medical management follow up visits.

  • Most often medication management is done every one to three months, but sometimes more often at the beginning of treatment and during periods of acuity.

  • Most often medication management continues for several years or even longer; because of this variability, please ask us what can be expected in your case.

  • It is your right to determine your goals for treatment and how long you want to remain with condition and medication management with your FAMh provider.

No Show Fees

In order to ensure efficient scheduling and accommodate our patients' needs, we kindly request a 48-hour notice from your scheduled visit time or sooner for cancellations. Should you need to cancel or reschedule, please be aware that a late cancellation or no-show fee will apply if you cancel within this period. Given we reserve your time slot, we generally are unable to fill a changed appointment time with less than 72 hours notice.

To assist you in remembering your appointment, we have multiple methods via email and text (SMS) to provide you advance notice of your appointment. Providing us with the required notice allows us to better manage our appointments and potentially offer slots to patients on our waiting list if your appointment needs to be adjusted.

If you miss your appointment, your credit card on file will be charged accordingly. We appreciate your understanding and cooperation so we can best serve you and our other patients.

  • $150 / Initial visit no show fee

  • $75 / Follow up visit no show fee

  • $25 / Month will accrue on any past due balances

If you find yourself unable to attend your appointment due to a sudden illness or an unforeseen personal emergency, please get in touch with our office promptly. You can reach us at (877) 400-0540, utilize your portal's chat feature to message your provider, or send an email to info@forallmentalhealth.com as soon as you become aware of your appointment conflict. If you were not able to notify us in advance and would like to request a waive of your no show fee due to sickness, we do require a doctor's note or formal documentation to consider the request. Please note, not all requests will be granted.

The no show fees are your financial responsibility and they are not covered or reimbursed by your insurance provider.

Patients who do not settle their no-show fees will be unable to book future appointments until the fee is paid in full or suitable payment arrangements have been established. Repeated late cancellations or no-show incidents may lead to dismissal from our practice. 

We remain dedicated to assisting you with your mental and behavioral well-being. Your timely communication is greatly appreciated to avoid any of the aforementioned issues.

Required Disclaimers

  • Should you have additional questions about your rights under this act, you can contact any of the following: The U.S. Centers for Medicare & Medicaid Services (CMS) at 1- 800-MEDICARE (1-800-633-4227) or visit https://www.cms.gov/NoSurprises for more information about your rights under federal law. The Florida Office of Insurance Regulation https://www.floir.com/. 

  • If you are billed for more than this Good Faith Estimate you have the right to dispute the bill. You may 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 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 healthcare provider, you will have to pay the higher amount.

Insurance Reimbursement Notice

FAMh is in the process of expanding our network to include various insurance plans from multiple providers. If you plan to use insurance or an employee assistance program to cover our services, please note the following:

  1. We will require and accept your copayment at the time of your appointment.

  2. Our team will file your claim with your insurance provider.

  3. We will receive payments from your insurance provider.

  4. At your appointment, we expect you to settle any remaining portion, including copays, co-insurance, deductibles, or fee differences.

For insurance providers that we do not currently accept, we can provide you with a Superbill.

Moreover, by acknowledging this notice, you are consenting to the following:

  1. Allowing FAMh to directly invoice my insurance provider for the services rendered to me, the patient.

  2. Granting FAMh the authority to disclose any necessary information to the insurance company for payment processing purposes, appointing FAMh as my authorized representative to act on my behalf in securing payment.

  3. Transferring all my entitlements to claims and payment from my insurance to FAMh.

  4. Committing to cooperate with the claims process as required by FAMh or my insurance provider.

I am aware that if my insurance plan mandates that I satisfy a deductible amount before insurance coverage takes effect, I will be responsible for covering the entire session fee until the required deductible amount has been met. I acknowledge that not all mental health issues, conditions, and concerns addressed in psychotherapy may be eligible for reimbursement by insurance companies.

It's important to understand that FAMh files insurance claims as a courtesy to you, and the ultimate responsibility for your bill lies with you, not your insurance company. In the event that your insurance company denies a claim filed on your behalf, you are responsible for covering the difference between the standard rate and the copayment previously paid unless alternative arrangements have been approved by FAMh.

If your insurance status changes, please ensure that you present your new insurance card or information before or at the time of your next appointment. Failure to do so may result in your responsibility for the entire cost of the appointment.

Acknowledgement of Agreement

By signing this form, you agree to pay the full fee at the time of your treatment, unless otherwise arranged or if your clinician is in-network with your insurance. Any and all negotiated exceptions or arrangements are required to be signed off by a FAMh representative. If in-network, any co-pays or co-insurance are due at time of service.

I have thoroughly reviewed the Agreement and Policy mentioned above, and I have been provided with a copy for my personal records. I fully comprehend the policy, and by affixing my signature below, I willingly accept its terms concerning outpatient services administered by FAMh.

I have been duly informed that in the event I am not enrolled in a health plan, have no coverage, or do not intend to file a claim with my current plan or coverage, I have received both oral and written notification of my entitlement, upon request or at the time of scheduling healthcare items and services, to obtain a "Good Faith Estimate" of anticipated charges.

I acknowledge my understanding of this explanation and, by signing below, confirm that I have been apprised of my "Right to Receive a Good Faith Estimate of Expected Charges." Your agreement binds you by our terms related with outpatient services provided by FAMh.