Good Faith Estimate for
Healthcare Items and Services
Big Picture Therapy
3401 Glendale Blvd. #B
Los Angeles, CA 90039
Phone: (323) 508-3231
Email: chauney@bigpicturetherapy.org
Tax ID: 33-2575199
Your Rights and Protections Under the No Surprises Act
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.
You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service, or at any time during treatment.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. You may contact the U.S. Department of Health and Human Services (HHS) at 1-800-985-3059 or visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
Good Faith Estimate of Expected Charges
This Good Faith Estimate shows the expected charges for psychotherapy services provided by Big Picture Therapy. This is only an estimate based on the information known at the time the estimate was created. The actual charges for your services may be different from this estimate.
Provider Information
Provider Name: Chauney Peck, LMFT #103576
Practice Name: Big Picture Therapy
Expected Service Information
Standard Psychotherapy Services
The following are typical fees for psychotherapy services at Big Picture Therapy:
| Service Description | CPT Code | Expected Fee Per Session |
| Initial Intake Session (60 minutes) | 90791 | $250 |
| Individual Therapy (53+ minutes) | 90837 | $250 |
Note: Actual session length and frequency will be determined based on your individual clinical needs.
Estimated Treatment Plan
Typical Treatment Approach:
- Initial Phase: Assessment and treatment planning (1-3 sessions)
- Active Treatment Phase: Weekly sessions (frequency may vary based on clinical need)
- Estimated Duration: Treatment duration varies based on individual needs; typical estimates range from 12-24 sessions
Sample 3-Month Estimate (Weekly Sessions)
| Service | Number of Sessions | Cost Per Session | Total Cost |
| Initial Intake (90791) | 1 | $250 | $250 |
| Individual Therapy (90837) | 12 | $3000 | $3,250 |
TOTAL ESTIMATED COST (3 months)
$3,250
Sample 6-Month Estimate (Weekly Sessions)
| Service | Number of Sessions | Cost Per Session | Total Cost |
| Initial Intake (90791) | 1 | $250 | $250 |
| Individual Therapy (90837) | 24 | $250 | $6000 |
| TOTAL ESTIMATED COST (6 months) | $6250 |
Sample 12-Month Estimate (Weekly Sessions)
| Service | Number of Sessions | Cost Per Session | Total Cost |
| Initial Intake (90791) | 1 | $250 | $250 |
| Individual Therapy (90837) | 48 | $250 | $1200 |
| TOTAL ESTIMATED COST (12 months) | $12250 |
Your individualized Good Faith Estimate will be provided based on your specific treatment needs and goals.
Important Disclaimers and Information
This is an Estimate, Not a Contract
This Good Faith Estimate is not a contract and does not obligate you to obtain services from Big Picture Therapy. You are not required to accept this estimate or proceed with treatment.
Actual Charges May Differ
The actual charges for your treatment may be different from this estimate for several reasons, including:
- Changes in your diagnosis or treatment needs
- Changes in the frequency or duration of sessions
- Unforeseen clinical circumstances that require different services
- Addition of services not originally anticipated (such as coordination of care, extended sessions, or crisis intervention)
- Changes in your treatment goals
- Early termination or extension of treatment beyond the estimated period
When You Will Receive an Individualized Estimate
You will receive a personalized Good Faith Estimate:
- Before your first session: At least one business day before your scheduled appointment
- Upon request: At any time you ask for cost information
- When treatment changes: If your treatment plan changes significantly
- Annual updates: At least every 12 months for ongoing treatment
Your Right to Dispute Bills
If you are billed for an amount that is at least $400 more than the Good Faith Estimate you received, you have the right to dispute the charges through the Patient-Provider Dispute Resolution (PPDR) process.
To initiate a dispute:
- Contact the PPDR process at 1-800-985-3059 or visit www.cms.gov/nosurprises
- You must start the dispute within 120 calendar days of the date on your bill
- There is an administrative fee to use the PPDR process (fee amount set by federal regulations)
We encourage you to contact our office first if you have questions or concerns about your bill before initiating a formal dispute.
Payment Policies
- Payment is due at the time of service unless other arrangements have been made in advance
- Accepted payment methods: Cash, check, credit card, HSA/FSA cards
- Late cancellation/no-show policy: [Insert your policy and fee]
- Sliding scale: [If applicable, state whether sliding scale fees are available]
Insurance Information
This Good Faith Estimate applies to uninsured patients or patients who choose not to use their insurance (self-pay).
If you have insurance:
- We recommend contacting your insurance company to understand your coverage and out-of-pocket costs
- You may choose to not use your insurance and pay out-of-pocket, in which case this Good Faith Estimate applies
- If you use insurance, your costs will be determined by your insurance plan’s coverage and our contracted rates
Services Not Included in This Estimate
This estimate does not include charges for:
- Services provided by other healthcare providers (psychiatrists, medical doctors, other specialists)
- Coordination of care with other providers (when extensive)
- Written reports, letters, or completion of forms (if requested)
- Legal consultations or court-related services
- Services provided outside of regular therapy sessions
If these additional services become necessary, you will be notified and provided with fee information before services are rendered.
Questions or Concerns
If you have questions about this Good Faith Estimate or need clarification about expected costs, please contact us:
Phone: (323) 508-3231
Email: chauney@bigpicturetherapy.org
We are committed to transparency in our billing practices and want to ensure you understand the expected costs of your treatment.
Additional Resources
For more information about your rights under the No Surprises Act:
- U.S. Department of Health and Human Services: www.cms.gov/nosurprises
- Consumer Information Hotline: 1-800-985-3059
- Patient-Provider Dispute Resolution: www.cms.gov/nosurprises/consumers
Acknowledgment
This Good Faith Estimate is provided in compliance with the No Surprises Act (effective January 1, 2022). By receiving services from Big Picture Therapy as an uninsured or self-pay patient, you acknowledge that you have received and reviewed this information.
Individualized Good Faith Estimates with specific cost calculations based on your treatment plan will be provided before services begin.
© 2025 Big Picture Therapy. All rights reserved.
This document is for informational purposes and represents general fee information. Your personalized Good Faith Estimate will be provided before treatment begins and will include specific cost calculations based on your individual treatment needs.