**Notice required under the No Surprises Act (effective January 2022)

Your Right to a Good Faith Estimate

Under the No Surprises Act, you have the right to receive a Good Faith Estimate explaining how much your mental health care will cost before you begin services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill.

About Mountain River Therapy

Provider: Jarae Swanstrom, LCPC License: Idaho LCPC #8331208 Address: 1224 Washington Ave, Suite 206, Sandpoint, Idaho 83864 Phone: 208-684-0512 Email: jarae@mountainrivertherapy.com

Services and Fees

Mountain River Therapy offers individual psychotherapy sessions. The following fee information is provided as a general estimate of expected costs:

Individual Therapy Session Session length: 53 minutes Fee: $185 per session

Reduced Fee Rate A reduced fee rate is available upon request for clients who demonstrate financial need. Please discuss this with Jarae Swanstrom, LCPC during your free consultation call.

Insurance

Mountain River Therapy is currently in-network with Blue Cross of Idaho only.

If you are using Blue Cross of Idaho insurance, your actual out-of-pocket costs will depend on your individual plan, deductible, copay, and coinsurance. It is your responsibility to contact Blue Cross of Idaho to verify your mental health benefits before beginning services.

If you are a self-pay client (not using insurance), your fee will be $185 per session unless a reduced fee rate has been agreed upon in writing.

Estimated Total Cost

The total cost of your care depends on the number of sessions you attend. The length of treatment varies significantly from person to person and cannot be predetermined. The following are general estimates only:

Number of Sessions

Estimated Total Cost (Self-Pay)

4 sessions

$740

8 sessions

$1,480

12 sessions

$2,220

24 sessions

$4,440

These estimates are based on the standard session rate of $185 and do not account for insurance benefits, reduced-fee agreements, or missed-appointment fees.

Additional Costs

The following services may result in additional fees and will be discussed with you in advance:

• Clinical documentation requested by a third party (letters, reports, records)

• Court appearances or legal consultations

• Extended phone or email consultations beyond routine scheduling

Cancellation Policy

A cancellation fee may apply for appointments canceled with less than 24 hours’ notice. This fee will be outlined in your client agreement prior to the start of services.

Important Note

This Good Faith Estimate is not a contract and does not obligate you to receive services from Mountain River Therapy. It is provided for informational purposes to help you understand the potential cost of services before you begin treatment.

For questions or concerns about your Good Faith Estimate, please contact:

Jarae Swanstrom, LCPC, Mountain River Therapy, 1224 Washington Ave, Suite 206, Sandpoint, Idaho 83864, jarae@mountainrivertherapy.com, 208-684-0512

Dispute Resolution

If you receive a bill that is at least $400 more than this Good Faith Estimate, you have the right to dispute the bill. For more information about your rights under the No Surprises Act, visit cms.gov/nosurprises or call 1-800-985-3059.

Document prepared for Mountain River Therapy | Jarae Swanstrom, LCPC mountainrivertherapy.com These documents are provided as a general template and are not intended as legal advice. Mountain River Therapy recommends consulting with a healthcare attorney to ensure full compliance with all applicable state and federal regulations.