Your Right to a Good Faith Estimate

Under the federal No Surprises Act, you have the right to receive a Good Faith Estimate of the total expected cost of any non-emergency care, if you are uninsured or if you are not using insurance to pay for a service.

A Good Faith Estimate is a written document, prepared for you, that sets out what we expect your care to cost before you commit to it. It covers the visit itself and everything we reasonably expect to provide alongside it — the evaluation, the follow-up visits planned as part of the same course of care, medication given in the office, and monitoring time.

Most of what we do falls under this right. IV ketamine, medication management and psychotherapy are out-of-network here: you pay at the time of your visit and we give you a superbill afterwards. For the purpose of this notice we treat you as self-pay in that situation — including when you intend to send the superbill to your own plan for reimbursement — so you are entitled to an estimate.

Spravato is the exception, because we bill it to insurance directly. When we are billing a plan for a service, that service sits outside this notice and what you want instead is a benefits check, which we carry out before your first session. How coverage works per treatment is set out on our insurance page. If you would rather pay for Spravato without using insurance, say so, and you get a Good Faith Estimate for it like anything else.

This notice is written in plain language on purpose. Nothing here depends on you knowing a billing code or a regulation, and nothing you ask about cost will be held against you.

1. 1.You can ask before you schedule anything. You do not have to book an appointment, or become a patient, to find out what something costs.
2. 2.You receive it in writing before the appointment. If your appointment is three or more business days away, we send your estimate within one business day of scheduling — so it reaches you at least a full business day before you are seen.
3. 3.Booking further ahead gives you more time. If your appointment is ten or more business days away, we send your estimate within three business days of scheduling, leaving you a week or more to read it and think.
4. 4.If you simply request one, you get it within three business days. No appointment required, no fee, no obligation to book afterwards.
5. 5.Any question about cost counts as a request.If you ask what something costs — on the phone, in the office, or through the form on our contact page— we treat that as a request for a Good Faith Estimate and start the clock, whether or not you use those words.
6. 6.If your care changes, you get a new estimate. When the plan changes enough that the figures no longer hold, we issue a revised estimate rather than letting the old one quietly go stale.
7. 7.The estimate is not a bill and not a contract. It does not obligate you to go ahead with the care, it does not commit you to an appointment, and it does not by itself mean you owe anything. You can take it away, compare it, or decide against treatment entirely.

One limit worth knowing: if you book an appointment fewer than three business days away, the timing rules above do not apply to it. Ask us anyway — we will get you an estimate as quickly as we can, and in practice that is usually the same day.

What is in the estimate

• Your name and date of birth.
• A plain-language description of the service, for example an initial psychiatric consultation.
• The service codes and diagnosis codes we expect to bill under, so the figures can be checked against a real bill later.
• An itemised list of everything we reasonably expect to provide as part of that care, with the expected charge for each item and a total.
• Who is providing the care — Dr. Omidvari and Omidvari Psychiatry P.C., with our provider identifiers and this office address. Those identifiers are published and independently checkable on our credentials page.
• Anything that would need to be scheduled separately, listed so that it is visible to you now rather than as a second bill later.
• The disclaimers the regulation requires, including that the estimate is not a contract and that your actual charges may differ from it.

There is no form to complete and no charge. Ask, and we prepare it.

By phone

Call (646) 874-9340 during office hours (Monday to Friday, 9:00 am to 8:00 pm Eastern Time).

Online

Use the form on our contact page and tell us you would like a Good Faith Estimate.

When you schedule

Tell whoever books your appointment. We are also required to raise this with you out loud at the time of scheduling, so you should not have to think of it yourself.

What helps us make it accurate

• Which service you are asking about: an initial consultation, ongoing medication management, psychotherapy, or a course of IV ketamine.
• Whether you have insurance, and whether you want us to bill it. This does not change what you pay for the services we do not bill; it tells us which of your two rights applies.
• Roughly how often you expect to be seen, if you already have a sense. Weekly psychotherapy and monthly medication follow-ups produce very different totals over a year.
• Anything a previous clinician has told you about the treatment you are seeking, so that the codes we estimate against match the care you actually need.

We can only estimate the care we provide ourselves. If part of your treatment involves someone else — a laboratory, a pharmacy, a therapist you see elsewhere — that provider owes you their own Good Faith Estimate, and we will tell you when that is the case rather than leaving a gap in the total.

How you receive it, and what we keep

You receive the estimate in writing, on paper or electronically, whichever you prefer. Tell us which suits you; if you do not say, we will ask before sending it.

We keep a copy of every Good Faith Estimate we issue in your record for at least six years, and we will give you another copy at any point in that period if you ask for one.

If you receive a bill from us that is at least $400 more than the Good Faith Estimate we gave you, you can dispute it through a federal process. You do not need a lawyer, and you do not need our agreement to start.

1. 1.Start within 120 calendar days from the date on the bill. The deadline is firm, so do not wait to see whether the bill is corrected on its own.
2. 2.Go to www.cms.gov/nosurprises or call 1-800-985-3059. That is where the form and the step-by-step instructions live. There is a small administrative fee set by the Department of Health and Human Services; the current amount is stated on that page.
3. 3.Have both documents to hand. You will be asked for your Good Faith Estimate and for the bill you are disputing, which is why keeping a copy matters.
4. 4.An independent reviewer decides.The dispute is settled by a third-party entity selected by the federal government — not by us, and not by an insurer.

Disputing a bill does not affect the care you receive from us. We will not discharge you, refuse to see you, or treat you any differently because you questioned a charge.

The quickest route is often the simplest one: call us first. Most differences between an estimate and a bill turn out to be an error we can find and correct the same day, and starting a federal dispute does not stop you from talking to us at the same time.

We publish our two standard self-pay charges so that nobody has to ask for the basics. All amounts on this site, and in any estimate we issue, are in USD (United States dollars).

Initial psychiatric consultation

US$490

Follow-up session

US$275

These published figures are not themselves a Good Faith Estimate. They are the standard charge for two common visits, quoted without any knowledge of your situation. Your Good Faith Estimate is prepared for you: it names the services you are actually expected to need, the codes they will be billed under, how many visits are anticipated, and a total.

Not every treatment has a single flat price. A course of IV ketamine depends on how many sessions you and Dr. Omidvari plan together. If you are considering it and paying without insurance, ask for a Good Faith Estimate before you decide — it will give you the full expected cost of the course in writing, which is exactly what it is for.

When payment is taken, what happens if you need to cancel or reschedule, and how refunds are handled are all set out in our Fees, Payment and Cancellation Policy. Which treatments we bill to insurance, and which are out-of-network, is on our insurance page.

This notice and your Good Faith Estimate are available in large print, electronically, read aloud to you, and in languages other than English. There is no charge for any of it, and no one is treated differently for asking.

To ask, call (646) 874-9340 and tell us what would work for you. We can provide:

• Large print, or a plain electronic copy that works with a screen reader.
• Someone reading the estimate to you, on the phone or in the office, and answering questions about it.
• A qualified interpreter at no cost to you, for the conversation about cost as well as for your appointment.
• This notice, and your estimate, translated into the language you prefer.

Language assistance and auxiliary aids are described in full in our Notice of Nondiscrimination, and the standard this website itself is built to is set out in our Accessibility Statement. If the website is the barrier, call us and we will take your request by phone instead.

Wele Clinic is the registered assumed name of Omidvari Psychiatry P.C., a New York domestic professional service corporation.

If anything here is unclear, or you want an estimate and are not sure how to ask for one, call us. A question about cost is never a nuisance — it is the request that starts this whole process.

Practice

Omidvari Psychiatry P.C., trading as Wele Clinic

Office

1123 Broadway, Suite 1117, New York, NY 10010

Phone

(646) 874-9340

Office hours

Monday to Friday, 9:00 am to 8:00 pm Eastern Time

Federal help line

cms.gov/nosurprises or 1-800-985-3059