Good Faith Estimate for Self-Pay Mental Health Care

Need a superbill for insurance? Self-pay patients with eligible out-of-network benefits may request a superbill after services are rendered. Superbills include applicable CPT codes and other information needed for submission to your insurance plan. Reimbursement is determined by your insurance carrier and is not guaranteed.

Effective Date: September 3, 2026

Last Updated: October 4, 2026

At Sunset Behavioral Health, we believe in clear and transparent pricing. You have the right to receive a Good Faith Estimate (GFE) explaining the expected cost of your psychiatric care when you do not have insurance or choose not to use insurance to pay for your care.

Under the federal No Surprises Act, uninsured and self-pay patients may request a Good Faith Estimate for scheduled non-emergency healthcare services. A Good Faith Estimate is not a bill. It is an estimate of the charges that can reasonably be expected based on the services anticipated at the time the estimate is prepared.

## Self-Pay Rates

### Comprehensive Psychiatric Evaluation — $199

Self-pay psychiatric care begins with a comprehensive psychiatric evaluation for $199.

After your initial evaluation, you may choose one of two options for ongoing care:

### Option 1: Mental Health Membership — $149 per month

The Mental Health Membership begins at your 2-week follow-up and continues month-to-month at $149 per month.

The membership includes:

- Psychiatric follow-up care

- Medication management and medication adjustments when clinically appropriate

- Supportive, solution-focused therapeutic care integrated into psychiatric visits

- Secure patient portal messaging for non-urgent questions and care coordination

- Priority scheduling based on availability

- Continuity of care with the same psychiatric provider

- Telehealth psychiatric care throughout Florida

There are no long-term contracts.

The Mental Health Membership is a self-pay arrangement and is not health insurance and does not replace health insurance.

### Option 2: Pay-As-You-Go — $149 per Follow-Up Visit

Patients who do not wish to enroll in the monthly membership may choose Pay-As-You-Go psychiatric follow-up care for $149 per visit.

There is no monthly membership fee or long-term commitment. Each psychiatric follow-up visit is billed separately at $149 per visit.

### Returning After an Extended Break in Care

If a patient enrolled in the Mental Health Membership has no visits for 3 consecutive months, the membership will end.

When returning to care after this period, care restarts with a $199 comprehensive psychiatric evaluation. The patient may then choose the Mental Health Membership or Pay-As-You-Go option for ongoing care.

## Documentation and Letter Fees

Certain documentation may be available to established patients when clinically appropriate and supported by the medical record.

Diagnosis Letter: $39 — available after at least 30 days of established care

Emotional Support Animal (ESA) Letter: $129 — available after at least 60 days of established care

FMLA Short-Term Leave Application: $129 — available after at least 30 days of established care

FMLA Application Revision: $59

Accommodation Letter: $30 — available after at least 30 days of established care

504/IEP Supporting Documentation: $39 — available after at least 30 days of established care when clinically appropriate and supported by the medical record. Eligibility for a 504 Plan or IEP and specific educational accommodations are determined by the school or school district.

Letters, forms, and other documentation are not provided at the initial visit and are not guaranteed. All documentation requests are subject to clinical evaluation, appropriateness, support in the medical record, and the provider's professional judgment. Payment does not guarantee that a particular letter, certification, accommodation, or recommendation will be issued.

## Insurance and Out-of-Network Reimbursement

Sunset Behavioral Health accepts many insurance plans.

If you choose to self-pay and have eligible out-of-network benefits, we may provide a superbill after services are rendered that you can submit to your insurance company for possible reimbursement.

Reimbursement is determined by your insurance plan and is not guaranteed by Sunset Behavioral Health.

Patients enrolled in Medicare, Medicaid, or other government healthcare programs may be subject to separate federal and program-specific billing requirements and protections. Please contact Sunset Behavioral Health before choosing a self-pay option if you participate in a government healthcare program.

## When Can I Request a Good Faith Estimate?

If you are uninsured or are not using insurance to pay for your care, you may request a written Good Faith Estimate before receiving scheduled non-emergency services.

When applicable under federal law, Sunset Behavioral Health will provide your Good Faith Estimate within the required timeframe based on when your care is scheduled or when your request is received. Good Faith Estimates generally apply when care is scheduled at least 3 business days in advance or when an estimate is requested.

## What If My Bill Is Higher Than My Estimate?

If you receive a bill from a healthcare provider or facility that is at least $400 more than the Good Faith Estimate from that provider or facility, you may be eligible to use the federal patient-provider dispute resolution process.

Keep a copy or photograph of your Good Faith Estimate for your records and compare it with your final bill.

For additional information about your rights under the No Surprises Act and Good Faith Estimate requirements, visit CMS.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.

## Sunset Behavioral Health

Sunset Behavioral Health LLC provides virtual psychiatric and mental health care throughout Florida for eligible children, adolescents, and adults.

Care is provided by Luisa Garcia, APRN, FNP-C, PMHNP-BC, a dual-certified Family Nurse Practitioner and Psychiatric Mental Health Nurse Practitioner.

Services include psychiatric evaluations, medication management, and supportive therapeutic care delivered virtually throughout Florida.

English and Spanish care is available.

Appointments are often available within 48 hours, depending on eligibility and current availability.

Sunset Behavioral Health LLC

Phone/Text: (239) 790-8822

Fax: (561) 257-3956

Email: info@sbhmind.com

If you are experiencing a medical or mental health emergency, call 911 or go to the nearest emergency department. If you are experiencing a mental health crisis, call or text 988 for the Suicide & Crisis Lifeline.