Good Faith Estimate

This Good Faith Estimate is provided under the federal No Surprises Act. Please review it carefully.

Provider information

Fluid Nature Therapy PLLC
3801 Stone Way N, Seattle, WA 98103

Name: Sky Kili, LICSWA
NPI: 1043180565
TIN: 42-4968259

Client information

Client name, client date of birth, and the date of this estimate are completed individually for each client.

Estimated cost of services provided

The cost of each 60 minute clinical session is $150.

Diagnosis (when applicable)

I am not able to propose an appropriate diagnosis or course of treatment for you until we have spent some time together. As soon as I am able to identify a diagnosis and an appropriate course of treatment, I will discuss it with you. Your diagnosis, if any, will have no impact on the amount you are billed.

Estimated duration of recurring services under this estimate

This Good Faith Estimate of client costs is effective through the end of 2026.

Description of services provided

Counseling and/or psychotherapy as indicated on a recurring basis.

Important disclosures

This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to us when we did the estimate.

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 your billed charges are at least $400 more than this Good Faith Estimate, you may be eligible to use the federal patient-provider dispute resolution process.

If you are billed at least $400 more than this Good Faith Estimate, you may have the right to dispute the bill.

If the billed charges are higher than this Good Faith Estimate, you may contact me to discuss the bill. You can ask to have the bill updated to match the Good Faith Estimate, ask to negotiate the bill, or ask whether financial assistance is 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 www.cms.gov/nosurprises or call CMS at 1-800-985-3059.

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

This Good Faith Estimate is not a contract. It does not obligate you to obtain clinical services from me.

Questions

If you have questions about this estimate, contact me at skykili@fluidnaturetherapy.com or (206) 395-8372.