Policy Effective Date (Clinic Policy): 01/01/2026

Document Created/Revised: 12/26/2025

Patient Signature Date/Time: Captured electronically by the patient portal and controls as to when you become bound

Practice: DVH NP IN PSYCHIATRY SERVICES (“DVH,” “Practice”)

Contact: office@dvhnpinpsychiatryservices.com

IMPORTANT — READ THIS FIRST (PRIVATE-PAY PRACTICE / NO INSURANCE CLAIMS)

DVH is not in-network with any insurance plans. DVH does not submit insurance claims. DVH does not submit superbills to insurance.

All services are private pay, and payment is due at the time of service unless DVH agrees otherwise in writing.

If you wish to seek possible out-of-network reimbursement, DVH may provide a superbill for paid sessions upon request; you are responsible for submitting it to your insurer. Any reimbursement is determined solely by your plan and is not guaranteed.

YOUR RIGHT TO A GOOD FAITH ESTIMATE (FEDERAL LAW NOTICE)

The No Surprises Act is a federal law that went into effect on January 1, 2022. If you are uninsured, or if you have health coverage and choose not to use it for DVH services (i.e., you are self-pay), you have the right to receive a Good Faith Estimate of expected charges for medical items and services.

This GFE is an estimate only. It is not a contract, and it does not require you to schedule or receive services from DVH.

Note on federal programs: Individuals enrolled in federal health care programs (such as Medicare or Medicaid) are generally not eligible to receive a Good Faith Estimate under these requirements. DVH’s policies also restrict enrollment/coverage types it will accept for services.

SERVICE MODALITY & LOCATION REQUIREMENTS

Service Modality: Telehealth (video; audio-only may be used when clinically appropriate and permitted)

Patient Location Requirement: You must be physically located in a state where the rendering clinician is duly licensed/authorized for your location at the time of the visit.

Your legal name and identifying information are maintained in Tebra/Kareo based on your records and signature.

Accessible formats and language assistance are available upon request.

CONVENING PROVIDER / BILLING ENTITY (BILLING PROVIDER)

DVH NP IN PSYCHIATRY SERVICES (“DVH”) is the billing provider for the services described in this Good Faith Estimate. 

Phone: (347) 573-9479

Email: office@dvhnpinpsychiatryservices.com

Expected Treating Provider (Rendering Clinician): Dustin Von Holten, NPP-BC

Rendering Clinician NPI: 1841720521

Contracted / Affiliated Clinicians

DVH may arrange for services to be furnished by appropriately licensed/credentialed independent or contracted clinicians or professional entities under DVH’s operations. The treating provider and/or rendering clinician information will be shown on your visit documentation and, where applicable, on your superbill.

SEPARATE BILLING BY OTHER PROVIDERS / FACILITIES (OUTSIDE DVH)

This Good Faith Estimate covers only DVH’s professional services and DVH’s fees listed in this estimate.

IMPORTANT DISCLAIMER (READ)

This estimate does not include any items or services that are billed separately by other providers or facilities. If you schedule any separately billed items or services, you may request a separate Good Faith Estimate from the provider or facility that will bill you.

Examples of items/services that may be billed separately by others (if ordered or needed):

• Pharmacy/medication costs (billed by your pharmacy)

• Laboratory testing (billed by the laboratory)

• Imaging (billed by the imaging facility)

• Outside providers/facilities (primary care, specialty referrals, urgent/emergency care, etc.)

If you schedule services with an outside provider or facility that will bill you separately, that outside provider/facility is responsible for providing its own Good Faith Estimate upon scheduling or upon request.

ESTIMATED ITEMS/SERVICES & EXPECTED CHARGES (SELF-PAY)

THIS GOOD FAITH ESTIMATE IS FOR (PRIMARY ITEM/SERVICE)

Primary Item/Service (select one for this estimate):

1. Initial Psychiatric Evaluation (Telehealth)
2. 45-Minute Psychotherapy (Telehealth)
3. Medication Management Follow-Up (Telehealth)

Quantity Included in This Estimate: [# OF VISITS] (default: 1 visit unless otherwise stated)

Requested/Scheduled Service Date(s): [DATE(S)] (or “Not yet scheduled—estimate provided upon request”)

Coding Note (CPT/HCPCS & ICD-10-CM)

Service and diagnosis codes, when applicable, depend on clinical documentation and may not be finalized until after the visit. More than one diagnosis code may be used, and diagnosis may change over time as symptoms evolve and additional information becomes available. For initial evaluations where diagnosis is not yet determined, diagnosis may be documented as “TBD — to be determined after clinical assessment.”

All services in this estimate are furnished via telehealth to the patient’s physical location, which must be in a state that the treating provider is licensed.

1) Initial Psychiatric Evaluation (Telehealth)

Service/Item: Initial psychiatric evaluation (telehealth)

CPT/HCPCS (illustrative, if applicable): 90792 (telehealth modifier GT or 95, as applicable)

Self-pay rate: $255 per evaluation

2) 45-Minute Psychotherapy (Telehealth)

Service/Item: 45-minute psychotherapy (telehealth; may include medication management when clinically appropriate)

CPT/HCPCS (illustrative, if applicable):

• 90834 (telehealth modifier GT or 95, as applicable) OR
• 99213–99214 + 90836 (telehealth modifier GT or 95, as applicable; as documented)
• Self-pay rate: $189 per session

3) Medication Management Follow-Up (Telehealth)

Service/Item: Medication management appointment (telehealth; medication-focused follow-up; non-controlled medications)

CPT/HCPCS (illustrative, if applicable): 99213–99214 (telehealth modifier GT or 95, as applicable)

Self-pay rate: $129 per visit

TOTAL EXPECTED CHARGES FROM DVH (HOW TO ESTIMATE YOUR TOTAL)

Your total depends on the number and type of visits you receive. For planning purposes:

Total =

($255 × number of initial psychiatric evaluations)

• ($189 × number of 45-minute psychotherapy sessions)
• ($129 × number of medication management visits)

Medication management may be addressed during a 45-minute psychotherapy session when clinically appropriate; in those cases, an additional medication-focused visit may not be necessary.

CUSTOMIZED TOTAL ESTIMATES (OPTIONAL; NO OBLIGATION)

If you would like a customized total estimate based on your expected visit type(s) and frequency (for example, weekly therapy or monthly medication management), you may request one. Requesting or receiving a customized estimate does not obligate you to schedule or receive services from DVH.

Timing for customized total estimates (federal timeframes):

• If a visit is scheduled at least 3 business days before the date of service: within 1 business day after scheduling
• If a visit is scheduled at least 10 business days before the date of service: within 3 business days after scheduling
• If you request an estimate before scheduling: within 3 business days after your request

SUPERBILLS (OUT-OF-NETWORK REIMBURSEMENT — PATIENT SUBMISSION ONLY)

• DVH is out-of-network with all insurance plans.
• DVH does not submit insurance claims.
• DVH does not submit superbills to insurance.
• Upon request, DVH may provide a superbill for paid sessions for possible submission to your plan if your plan offers out-of-network benefits.

Superbills commonly include (as applicable):

• Rendering clinician name and NPI (e.g., Dustin Von Holten, NPP-BC; NPI 1841720521), or another rendering clinician as applicable
• Date(s) of service and place/modality of service (telehealth)
• CPT/HCPCS codes (and modifiers) used for that date of service
• ICD-10-CM diagnosis code(s) used for that date of service
• Amount charged and/or amount paid

Any reimbursement is determined by your plan and is not guaranteed.

ITEMS/SERVICES NOT INCLUDED (BILLED SEPARATELY BY OTHERS)

Examples (may apply depending on your plan of care; billed separately by those entities):

• Pharmacy/medication costs
• Laboratory testing (if ordered)
• Imaging (if ordered)
• Outside providers/facilities (primary care, specialty referrals, urgent/emergency care, etc.)

REQUIRED FEDERAL DISCLOSURES

1) Estimate Only

This Good Faith Estimate is based on information known at the time it was created. The charges listed are only an estimate of what is reasonably expected. Actual items, services, codes, or charges may differ.

2) Individualized Course of Care

Appointment frequency and length are determined collaboratively based on clinical needs and may change over time. If your course of care changes and you would like updated totals, request a customized estimate.

3) Right to Dispute Certain Bills (PPDR)

If you receive a bill from DVH for the services listed in this Good Faith Estimate and the total billed charges from DVH are $400 or more above the expected charges listed here, you may have the right to use the federal Patient-Provider Dispute Resolution (PPDR) process. Starting a dispute will not adversely affect the quality of health care services you receive.

Before starting PPDR, you may contact DVH if you believe your bill is higher than expected. You may ask DVH to:

• Review whether the bill matches this GFE and correct errors (if any)
• Discuss the charges and whether any adjustments are appropriate
• Discuss available payment options (if applicable)

PPDR contact (federal):

• Phone: 1-800-985-3059
• Email: FederalPPDRQuestions@cms.hhs.gov

Timing & fee (subject to change by HHS/CMS):

• You generally must start PPDR within 120 calendar days of the date on the original bill.
• An administrative fee applies to initiate the dispute and may change over time.

4) Not a Contract

This Good Faith Estimate is not a contract and does not require you to obtain the items or services from DVH.

PRESCRIBING SCOPE (DVH POLICY)

DVH does not prescribe controlled substances (Schedules II–V). “Medication management” refers only to non-controlled medications.

DELIVERY, RECORD RETENTION, AND COPIES

This Good Faith Estimate is provided electronically through the patient portal (Tebra/Kareo) in a format you can save and print, unless a paper copy is requested.

This Good Faith Estimate is part of the record. You may request a copy of any Good Faith Estimate issued to you within the past six (6) years.

Keep a copy of this Good Faith Estimate for your records; you may need it if you receive a bill higher than expected and choose to use the dispute process.

OPTIONAL PLANNING EXAMPLES (NOT PART OF THIS GOOD FAITH ESTIMATE)

The examples below are provided for planning only. They are not part of this Good Faith Estimate, are not a guarantee of total charges, and do not replace a customized estimate based on your scheduled or expected services. If you want a customized total estimate based on an expected frequency (e.g., weekly therapy or monthly medication visits), request one and DVH will provide it within the federal timeframes described above.

Examples using 2026 private-pay rates (effective 01/01/2026):

(45-minute psychotherapy sessions may include medication management when clinically appropriate within the session.)

• Initial psychiatric evaluation only: $255 total
• Medication visit, 6 months (monthly): 6 × $129 = $774
• Medication visit, 12 months (monthly): 12 × $129 = $1,548
• Therapy (45-min), 6 sessions: 6 × $189 = $1,134
• Therapy (45-min), 12 sessions: 12 × $189 = $2,268
• Weekly therapy (about 4/month):
• 6 months: 24 × $189 = $4,536
• 12 months: 48 × $189 = $9,072
• Weekly therapy (52 sessions/year, no missed visits): 52 × $189 = $9,828
• Biweekly therapy (26 sessions/year): 26 × $189 = $4,914
• Mixed example (4 therapy sessions + 4 medication visits): (4 × $189) + (4 × $129) = $1,272

Late cancel/no-show fees are not included in these totals.

ICD-10-CM Diagnostic Codes (Examples Only; Not Exhaustive)

The diagnosis code(s) used depend on your clinical presentation and documentation. You may have more than one diagnosis, and diagnosis codes may change over time. Your diagnosis may or may not be included in this list.

Mood disorders (F30–F39)

• F31.0–F31.9 Bipolar disorders (example: F31.81 Bipolar II disorder)
• F32.0–F32.9 Major depressive disorder, single episode
• F33.0–F33.9 Major depressive disorder, recurrent
• F32.A Depression, unspecified
• F34.1 Persistent depressive disorder (dysthymia)
• F34.81 Disruptive mood dysregulation disorder
• F32.81 Premenstrual dysphoric disorder
• F39 Unspecified mood disorder

Anxiety & obsessive-compulsive related disorders (F40–F42)

• F41.1 Generalized anxiety disorder
• F41.0 Panic disorder
• F40.10 Social anxiety disorder (social phobia), unspecified
• F40.2 Specific phobias
• F41.9 Anxiety disorder, unspecified
• F42.2 Mixed obsessional thoughts and acts
• F42.9 Obsessive-compulsive disorder, unspecified

Trauma- and stressor-related disorders (F43)

• F43.10 Post-traumatic stress disorder (PTSD), unspecified
• F43.11 PTSD, acute
• F43.12 PTSD, chronic
• F43.20 Adjustment disorder, unspecified
• F43.21 Adjustment disorder with depressed mood
• F43.22 Adjustment disorder with anxiety
• F43.23 Adjustment disorder with mixed anxiety and depressed mood
• F43.81 Prolonged grief disorder
• F43.9 Reaction to severe stress, unspecified

Dissociative disorders (F44)

• F44.81 Dissociative identity disorder

Psychotic disorders (F20–F29)

• F20.9 Schizophrenia, unspecified
• F25.9 Schizoaffective disorder, unspecified
• F29 Unspecified psychosis not due to a substance or known physiological condition

ADHD & neurodevelopmental disorders

• F90.0 ADHD, predominantly inattentive type
• F90.2 ADHD, combined type
• F90.9 ADHD, unspecified type
• F84.0 Autism spectrum disorder

Sleep-wake disorders

• F51.01 Primary insomnia
• G47.00 Insomnia, unspecified

Eating disorders (F50)

• F50.01 Anorexia nervosa, restricting type
• F50.02 Anorexia nervosa, binge eating/purging type
• F50.2 Bulimia nervosa
• F50.81 Binge eating disorder
• F50.82 Avoidant/restrictive food intake disorder (ARFID)
• F50.9 Eating disorder, unspecified

Substance-related and addictive disorders (F10–F19)

• F10.10 Alcohol abuse, uncomplicated
• F10.20 Alcohol dependence, uncomplicated
• F12.10 Cannabis abuse, uncomplicated
• F12.20 Cannabis dependence, uncomplicated
• F17.200 Nicotine dependence, unspecified, uncomplicated
• F17.210 Nicotine dependence, cigarettes, uncomplicated

Personality disorders (F60)

• F60.3 Borderline personality disorder
• F60.5 Obsessive-compulsive personality disorder
• F60.6 Avoidant personality disorder
• F60.7 Dependent personality disorder
• F60.9 Personality disorder, unspecified

Symptom codes / factors influencing care

• R45.851 Suicidal ideations
• Z79.899 Other long term (current) drug therapy

If you have questions about diagnosis codes listed on your visit documentation or superbill, contact DVH.

Standard Self-Pay Rates (Reference Only; Rates Depend on Date of Service)

Private-Pay Rates (effective 01/01/2026)

• Initial Psychiatric Evaluation (first appointment): $255
• 45-minute psychotherapy (with or without medication management): $189
• Medication management appointment (medication-focused visit): $129

Late Cancellation / No-Show Fees (Not Included in Estimate Totals)

• Initial Psychiatric Evaluation: $255
• Follow-Up Medication visits: $35
• Follow-Up Therapy sessions: $90

Questions or a customized estimate:

(347) 573-9479 | office@dvhnpinpsychiatryservices.com

NOTICE: Prices, fees, codes, and policies may be updated to reflect clinical, administrative, or regulatory changes. The rate in effect on the date of service applies unless a different written agreement is provided.