Good Faith Estimate of Expected Charges

Under the No Surprises Act

Your Rights

  • You have the right to receive a Good Faith Estimate for the total expected cost of non-emergency psychiatric services if you are uninsured or choosing not to use insurance.

  • This estimate must be provided in writing at least 1 business day before your service.

  • If your bill is $400 or more above the estimate, you may dispute the charges.

  • For more information, visit www.cms.gov/nosurprises.

Estimate of Costs

Because psychiatric treatment varies for each person, your actual cost may differ. The following are common scenarios for self-pay patients:

  • New Patient Evaluation – CPT 99204 + 90833

    • $425 with NP/PA

    • $600 with Psychiatrist

  • Extended Follow-Up Visit – CPT 99214 + 90833 (typically 25 min)

    • $250 with NP/PA

    • $300 with Psychiatrist

Example ScenarioS

  • Scenario A – with Psychiatrist

    • Initial evaluation ($600) + 12 extended follow-ups ($300 each)

    • Estimated Total = $4,200

  • Scenario B – with NP/PA

    • Initial evaluation ($425) + 12 extended follow-ups ($250 each)

    • Estimated Total = $3,425

Other Professional Services

Additional services may incur separate fees, such as:

  • Completion of forms (e.g., FMLA, disability)

  • Letters or narrative reports

  • Medical records requests

These fees are outlined in our Practice Policies.

Important Notes

  • This estimate is an over-estimation for most patients. Many require fewer visits.

  • You and your provider will decide together how often you should be seen.

  • The estimate does not include any reimbursement you may receive from your insurance for out-of-network claims.

  • Service codes (CPT/HCPCS) listed are examples of common psychiatric services. Your actual codes and charges may vary based on clinical circumstances.

  • This Good Faith Estimate is valid for 12 months from the date it is provided.

    📞 Questions? Email officemanager@vijapura.com.

Vijapura Behavioral Health PLLC
9141 Cypress Green Drive, Ste 1
Jacksonville, FL 32256
NPI: 1376904557 FEIN: 47-405-9133