Regulatory Disclosure

No Surprises Act & Good Faith Estimate

Provider: Hina Ansari, LPCC

Practice: The Healing Light Therapy LLC

Address: 34194 Aurora Road, #240, Solon, Ohio 44139

EIN: 871778320

License: E:2202965 (Ohio)

NPI 2: 1144996505

The Good Faith Estimate

Effective January 1, 2022, the No Surprises Act requires health care providers to give patients who are uninsured, or who are not using insurance, an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate explaining how much your medical and mental health care will cost. Under the law, health care providers must give patients who don't have insurance, or who are not using insurance, an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Who Qualifies as a Self-Pay Patient?

A self-pay patient is someone who is uninsured, or who has insurance but chooses not to use it for their care. If you are a self-pay patient, you are entitled to a Good Faith Estimate of the expected cost of your treatment before services begin.

Patients using in-network insurance benefits are not considered self-pay and will instead receive cost information through their insurer's benefits and claims process.

Good Faith Estimate Details

The following fee schedule reflects the standard charges for psychotherapy services at The Healing Light Therapy LLC. The number of sessions you need cannot be known in advance and will be discussed collaboratively and reviewed regularly.

Session fee schedule by CPT code

CPT Code Service Duration Fee
90791 Initial diagnostic intake evaluation 60 minutes $200
90834 Individual psychotherapy — follow-up session 45 minutes $120
90837 Individual psychotherapy — extended follow-up session 53+ minutes $150
90832 Individual psychotherapy — brief session 16–30 minutes $80

Estimated annual cost projections, based on standard follow-up sessions (code 90834):

Annual cost projections by session frequency

Frequency Estimated Annual Cost
Weekly (52 sessions per year, 90834) $6,240 per year
Biweekly (26 sessions per year, 90834) $3,120 per year
Quarterly (4 sessions per year, 90834) $480 per year

A rate change took effect January 1, 2023 for code 90834. EMDR Intensive packages are billed separately as flat-fee, cash-pay services: 6-hour Intensive $1,200; 8-hour Intensive $1,600; 3-day Intensive (18 hours) $3,600. All major credit cards accepted.

This Good Faith Estimate is not a contract and does not obligate you to obtain services. It shows only an estimate of the cost of items and services reasonably expected at the time the estimate is issued.

Questions About Session Costs

If you have any questions about the cost of your sessions, please call, text, or email: 440-252-2684 · hina@thehealinglighttherapy.com