Rates
$150 per 45-minute therapy or parent consultation session.
$150 per school meeting
School admissions testing rates are as follows:
- WPPSI-IV - $400
- WISC-V - $400
- Beery VMI - $20
Please call, email, or contact me via this website for rates for educational testing. Pricing is dependent upon the reason for testing and the type of testing that needs to be conducted.
Insurance
I do not participate in any insurance plans, but work with insurance companies as an out-of-network provider. Out-of-network services may be covered in full or in part by your health insurance plan.
To determine the reimbursement policies of your insurance provider, you may want to ask them:
- Do you provide any reimbursement for out-of-network providers?
- If yes, how much does my plan cover for an out-of-network provider?
- Is there a limit to the number of sessions per year that my plan covers for an out-of-network provider?
- Is approval required from my primary care physician?
Payment
Cash or checks are accepted for payment. Payment is due at time that services are provided.
Cancellation Policy
There is a 24-hour cancellation policy. Late cancellations or no-shows incur the full cost of the session.
Schedule Online
Request a therapy appointment online here.
Contact
Questions? Please call, email, or contact me via this website for further information.
In compliance with the No Surprises Act that goes into effect January 1, 2022, all healthcare providers are required to notify clients of their Federal rights and protections against “surprise billing.” This Act requires that I notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, if a client is uninsured, or if a client elects not to use their insurance. Additionally, I am required to provide you with a Good Faith Estimate of the cost of services (attached). It is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. Therefore, attached you will find a fee schedule for the services typically offered by me, and I will collaborate with you on a regular basis to determine how many sessions you may need. It is a Federal requirement that I have each client sign this form to begin/resume treatment. Please sign and date before your next appointment and return the signed document before your next appointment. If you have any questions, please don’t hesitate to ask.
THE NO SURPRISES ACT STANDARD NOTICE AND CONSENT DOCUMENTS
(OMB Control Number: 0938-1401)
SURPRISE BILLING PROTECTION FORM
The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care. You’re getting this notice because this provider or facility isn’t in your health plan’s network. This means the provider or facility doesn’t have an agreement with your plan. Getting care from this provider or facility could cost you more. If your plan covers the item or service you’re getting, federal law protects you from higher bills:
- When you get emergency care from out-of-network providers and facilities, or
- When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.
- You are giving up your protections under the law.
- You may owe the full costs billed for items and services received.
- Your health plan might not count any of the amount you pay towards your deductible and out- of-pocket limit. Contact your health plan for more information.
Ask your health care provider or patient advocate if you need help knowing if these protections apply to you. You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change. Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this provider or facility, or another one.
See the net page for your cost estimate.
Estimate of what you could pay
Patient name: Out-of-network provider(s) or facility name: Sara M. Evans, Psy.D.
Total cost estimate of what you may be asked to pay: It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy unless you are pursuing mandatory treatment. Please see the breakdown of possible fees on page four.
- Review your detailed estimate. See page four for a cost estimate for each item or service.
- Call your health plan. Your plan may have better information about how much of these services are reimbursable.
- Questions about this notice and estimate? Call Sara Evans at 215-880-9261
► Questions about your rights? Contact: The PA State Board of Psychology at 717-783-7155
Prior authorization or other care management limitations
Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.]
More information about your rights and protections
Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under federal law.
By signing, I give up my federal consumer protections and agree I might pay more for out-of-network care.
With my signature, I am saying that I agree to get the items or services from Sara M. Evans, Psy.D.
With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I also understand that:
- I’m giving up some consumer billing protections under Federal law.
- I may get a bill for the full charges for these items and services or have to pay out-of-network cost-sharing under my health plan.
- I was given a written notice on DATE explaining that my provider or facility isn’t in my health plan’s network, the estimated cost of services, and what I may owe if I agree to be treated by this provider or facility.
- I got the notice either on paper or electronically, consistent with my choice.
- I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit.
- I can end this agreement by notifying the provider or facility in writing before getting services.
FEDERAL TAX ID: 45-5620442
NPI#: 1417038241
More details about your estimate
Patient name:
Date of Birth:
Diagnosis:
Out-of-network provider(s) or facility name: Sara M. Evans, Psy.D.
The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate. Contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay.
GOOD FAITH ESTIMATE
TABLE OF SERVICES AND FEES
Client Name:
| Date of Service (If Known) | Service code (CPT Code) |
Description | Fee for Service (Number of Sessions Will Be Determined as We Progress) |
|
| 90791 | Initial Diagnostic Evaluation | $150 |
|
| 90834 | Psychotherapy, 38-52 minutes | $150 |
|
| 90846 | Family Psychotherapy without Patient Present, 50 minutes | $150 |
|
| 90847 | Family Psychotherapy with Patient Present, 50 minutes | $150 |
|
| Cancellation Fee | Your Therapist Requires a 24-Hour Cancellation Fee | You are Responsible for the Fee of the Appointment Missed |
|
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| Total Estimate: | This Good Faith Estimate explains your therapist’s rate for each service provided. Your therapist will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your diagnosis(es)/presenting clinical concerns. | |
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Please note that Place of Service (in office vs. telemental health) is not delineated above since the charges are identical.