Good Faith Estimate for Health Care Items and Services

Billing & Insurance
Five Rivers Mental Health Clinic files claims with insurance companies with whom we have contracts. If the insurance company refuses or delays payment, or pays only part of the bill, you are responsible for timely payment of the balance.

Five Rivers Mental Health Clinic will file claims with insurance companies with whom we do not have contracts. You will be responsible for any deductible, coinsurance, or arbitrary “usual and customary” reductions. You are responsible for all charges for services not covered by your insurance company.
Full payment is due at the time of your appointment unless other arrangements have been made in advance. We accept cash, personal checks, and credit cards. Checks returned for non-sufficient funds will result in an additional $15 fee and Five Rivers Mental Health Clinic will no longer accept your checks. Five Rivers Mental Health Clinic offers a 30% prompt payment discount for services paid in full on the date of service.

If Five Rivers Mental Health Clinic does not receive full payment by 60 days after the date of service, we will begin adding 1.5% interest each month, or the highest rate allowed by law, on all charges due to Five Rivers. Additionally, your account may be turned over to an outside collection agency. Acceptance of late or partial payments shall not waive any of Five Rivers Mental Health Clinic’s rights to collect the full amount due.

Good Faith Estimate for Health Care Items and Services
The estimate below is a list of possible services that are likely for most new clients. Until you complete an initial evaluation and treatment plan, we will not have a clear picture of your specific diagnosis, issues and needs. If you have questions about this estimate, please contact Renee at 507-345-7012 Ext. 116

Assessment Services
Automated Psychological Test $16.00
Brief Behavioral Assessment or Developmental Screen $7.00
Brief Diagnostic Assessment $130.00
Extended Diagnostic Assessment $370.00
Psychological Evaluation – 1 hour $155.00
Psychological Testing – 30 minutes $61.00
Standard Diagnostic Assessment $232.00
Updated Adult Diagnostic Assessment $130.00

Children’s Therapeutic Services and Supports (CTSS)
Administering & Reporting Standardized Measures $86.56
Comprehensive Community Support Services – 15 minutes $14.33
Comprehensive Multidisciplinary Evaluation – 15 minutes $36.00
Skills Training & Development – Family – 15 minutes $17.50
Skills Training & Development – Group – 15 minutes $9.03
Skills Training & Development – Individual – 15 minutes $13.44
Treatment Plan Development & Review $86.56

Family Therapy $175.00
Group Therapy $40.00
Interactive Complexity Additional Charge $20.00
Multi-Family Group Therapy $45.00
Prolonged Service Additional Charge $165.00
Psychoeducation – 15 minutes $30.00
Psychotherapy – 30 minutes $100.00
Psychotherapy – 45 minutes $165.00
Psychotherapy – 60 minutes $195.00

Additional Services
Fees for Providing Records – 1 page $0.75
Oral interpretive services $30.00
Travel Time – 1 minute $1.50

Children’s Mental Health Clinical Care Consultation
Face-to-face – 11-20 minutes $23.00
Face-to-face – 21-30 minutes $38.00
Face-to-face – 31 or more minutes $60.00
Non-face-to-face – 11-20 minutes $12.00
Non-face-to-face – 21-30 minutes $31.00
Non-face-to-face – 31 or more minutes $51.00

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The estimated costs are valid for 12 months from the date of the Good Faith Estimate. This reflects the price before any insurance payments. Please consult with your insurance to determine what portion of this will be your responsibility.

This Good Faith Estimate is not a contract. It does not obligate you to accept the services listed.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If you are charged over $400 more than this estimate, federal law allows you to dispute (appeal) the bill.

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 or call 1-877-696-6775.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit or call 1-877-696-6775.
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 more than $400 than the estimate provided.
Rev. 01/01/2022