Good Faith Estimate
For new patients: This document is an estimate of the anticipated services you will need while in treatment with Align Therapy Services, and the cost of each service. Until one of our therapists does an initial evaluation and starts to work with you, Align Therapy Services does not have a clear picture of your diagnosis and needs. As such, we will send you an updated estimate once we have completed a thorough assessment. To learn more about the Good Faith Estimate, please copy and paste the following link: https://www.cms.gov/nosurprises/consumers/understanding-costs-in-advance
For existing patients: This Good Faith Estimate reflects the services you currently receive at Align Therapy Services. If anything in this estimate changes, we will send you an updated Good Faith Estimate.
Total anticipated charges: The session fee for individual therapy with Dr. Larrain Montoni (Licensed Psychologist) is $310 for a 50-minute session. The total fee for therapy services will be the number of sessions multiplied by the ongoing session fee. The number of total sessions you may attend is flexible and based on your individual needs, preferences, and the progress made in the treatment.
Provider Information.
Align Therapy Services is a psychotherapy practice operating in the states of New York, Connecticut, and Washington D.C.. The physical address, contact information, and NPI listed below reflect our main business address in New York.
Provider type: private psychotherapy practice
Business address: New York, NY 10012
Contact person: Rachel Larrain Montoni, PhD
Phone: (646) 493-8084
Email: dr.montoni@aligntherapyservices.com
National Provider Identifier (NPI): 198-201-7505
Taxpayer Identification Number (TIN): 92-0619120
Additional healthcare provider notes: N/A
Disclaimer.
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your healthcare needs for an item or service. The estimate is based on information known at the time the estimate was created, and does not include any unknown or unexpected costs that may arise during treatment.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional services costs are in addition to the Good Faith Estimate. In such an instance, the provider would provide you with an updated estimate.
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 www.cms.gov/nosurprises or call 800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.