Good Faith Estimate
Good Faith Estimate of Expected Charges
For Mental Health Services at Full Circle Yoga & Therapy
Effective through: December 31, 2025
Overview of Your Right to a Good Faith Estimate
Under the No Surprises Act, you have the right to receive a Good Faith Estimate (GFE) explaining the expected costs of your mental health care. This estimate outlines the services you may receive and the associated fees, helping you plan for your care.
If you are billed $400 or more above this estimate per provider, you may dispute the charges.
For more information about your rights, visit www.cms.gov/nosurprises or call 1-800-985-3059.
Provider Information
Provider/Facility Name: Full Circle Yoga & Therapy
NPI: 1962898387
Tax ID: 46-5379996
Location(s):
1719 S. Main Street, Salt Lake City, UT 84115
Via Telehealth services within the state of Utah
Diagnostic Information
If you have not yet had an initial session, your provider will evaluate your needs over the course of your first few visits and provide a diagnosis aligned with your symptoms.
You have the right to decline a formal diagnosis. However, insurance providers require a diagnosis to process and pay claims.
If you decline to receive a formal diagnosis, you are responsible for 100% of service fees.
Estimated Costs for Services (Annualized)
This estimate assumes:
1 intake/evaluation appointment
51 weekly 60-minute psychotherapy sessions
Cost Breakdown:
Intake/Evaluation | CPT Code 90791| Cost per session: $200 | Quantity: 1 | Estimated Annual Cost: $200.00
Psychotherapy (60 min) | CPT Code 90837 | Cost per session: $150 | Quantity: 51 | Estimated Annual Cost: $7,650.00
Total Estimated Annualized Cost: $7,850.00
Additional Costs (If Applicable)
Play Therapy Supplies Fee: One-time $50 (not billable to insurance)
Interactive Complexity: $30 per session. Interactive Complexity applies to all play therapy sessions and to any other appointments which require specialized equipment (i.e. EMDR) or other care and coordination that complicates normal delivery of services.
After-Hours Appointments: $30 per session (applies to weekends, holidays, or start times at 5 PM or later)
If all additional fees apply, the maximum estimated annual cost may be up to $9,230.00.
You are only billed for services you actually receive. Late cancellation and no-show fees apply according to our standard policy.
Self-Pay Clients
If you:
Do not have insurance
Choose not to use insurance
…you are considered a self-pay client and are fully responsible for all fees.
If you have a reduced-rate agreement, your total estimated costs will be lower than stated above.
Insurance Billing Information
Full Circle Yoga & Therapy is in-network with the following providers:
Regence / Anthem / Blue Cross Blue Shield
Optum / UnitedHealthcare (UHC) / UMR / United Behavioral Health
Student Resources
EMI
Select Health (excluding Signature and Share plans)
Direct Care Administrators
We also accept:
Ecclesiastical reimbursement
Victims Reparations (where eligible)
Important Insurance Notes
We bill insurance at the same rates listed above.
Your insurance—not us—determines your out-of-pocket costs.
If you use an out-of-network provider, your out-of-pocket costs may be higher.
We do not accept Medicare, Medicaid, or PEHP—we do not bill them even for out-of-network services. This is true for all Medicaid and Medicare plans, even if your plan is managed by an insurance we are in-network with.
Late Cancel and No Show fees are not covered by insurance. You are fully responsible for any late cancel or no show fees that you incur.
If you use insurance, a formal diagnosis is required. If you decline a diagnosis, you must pay full service fees.
Disclaimer
This Good Faith Estimate is based on information known at the time of creation. It DOES NOT include:
Emergency or unforeseen services
Changes in session frequency or duration
Additional healthcare services
Non-clinical services (e.g., yoga classes, workshops, wellness experiences, product purchases, etc.).
These services may incur additional costs that are not billable to insurance. You assume full financial responsibility for any unforeseen additional costs that are not covered by your insurance. Non-clinical services are specifically not billable to insurance. We do not and have never billed insurance for non-clinical offerings and you understand that payment for utilizing these optional services will fully be your responsibility.
Dispute Process
If you are charged $400 or more above the estimate (per provider), you may:
Contact our billing office at jarohn@fullcircleut.com to request an updated bill or financial review.
Initiate a dispute resolution with the U.S. Department of Health and Human Services:
Must begin within 120 calendar days of the original bill
Fee: $25 (paid to HHS). This fee is your responsibility.
Visit www.cms.gov/nosurprises or call 1-800-985-3059 for more information.
Acknowledgment of Estimate
By accepting care at Full Circle Yoga & Therapy, you acknowledge that:
You understand this is a non-binding estimate and not a contract.
You are responsible for all fees not covered by insurance.
If you are a self-pay client, you will pay for all services out-of-pocket.
You may request an updated estimate at any time.
If you have any questions, please contact:
Jennifer Rohn, Director of Operations
📧 jarohn@fullcircleut.com