Good Faith Estimate & Patient Rights

Your Right to Receive a Good Faith Estimate

Under the federal No Surprises Act, patients who do not have health insurance or who choose not to use their health insurance to pay for medical services have the right to receive a Good Faith Estimate of expected charges for non-emergency health care services.

A Good Faith Estimate provides information about the anticipated cost of care before services are received. It is not a bill, does not guarantee a particular treatment plan, and does not obligate a patient to receive services.

About TESSERA Psychiatry

TESSERA Psychiatry is a private-pay psychiatric practice providing virtual care to children, adolescents, and adults across the lifespan who are physically located in Texas or Florida at the time of their appointment.

TESSERA Psychiatry does not bill insurance directly. In some cases, upon request, a superbill may be provided for patients to submit to their insurance carrier for potential out-of-network reimbursement. Reimbursement is not guaranteed.

TESSERA Psychiatry does not prescribe controlled substances, including stimulant medications and benzodiazepines.

Services, Duration and Fees

- Adult Initial Psychiatric Evaluation - 60 minutes: $380

- Child & Adolescent Initial Psychiatric Evaluation - 75 minutes: $475

- Medication Management / Follow-Up - 30 minutes: $190

- Extended Follow-Up / Psychotherapy, with or without Medication Management - 45 minutes: $285

Fees are based on the services provided. The total anticipated cost of treatment depends on the nature of the services and the expected frequency and duration of appointments.

How Treatment Costs Are Estimated

The number and frequency of appointments vary according to individual clinical needs. Some patients may benefit from more frequent follow-up visits, while others may require appointments less often.

When recurring services can reasonably be anticipated, an individualized Good Faith Estimate may include the expected number, frequency, and cost of appointments over a period of up to 12 months.

The initial evaluation helps determine an appropriate treatment plan. If the anticipated course of treatment changes, an updated estimate will be provided when required.

Charges for separately scheduled services from other providers, such as laboratory testing, pharmacy services, or specialized assessments, may be additional. Patients may request separate estimates from those providers.

When You Will Receive a Good Faith Estimate

Eligible uninsured or self-pay patients, including parents or legally authorized representatives requesting care on behalf of a minor, may request a written Good Faith Estimate.

For appointments scheduled 3–9 business days in advance, an estimate will be provided within 1 business day after scheduling.
For appointments scheduled 10 or more business days in advance, an estimate will be provided within 3 business days after scheduling.
When an estimate is requested before scheduling, it will be provided within 3 business days of the request.

Your estimate will identify the services and expected charges reasonably anticipated based on the information available at the time it is prepared.

Your Rights if Your Bill Exceeds the Estimate

If you receive a bill from a provider that is at least $400 more than that provider's Good Faith Estimate, you may be eligible to dispute the charges through the federal patient-provider dispute resolution process.

Generally, disputes must be initiated within 120 calendar days of the date on the initial bill.

You may contact the provider to discuss the charges or request clarification. You may also seek an independent review through the federal dispute resolution process.

Initiating a dispute will not adversely affect the quality of care you receive.

Patients are encouraged to keep a copy of their written Good Faith Estimate for their records.

Questions or Requests

To request a Good Faith Estimate or ask questions about anticipated treatment costs, please contact:

TESSERA Psychiatry
Garcia Psychiatry & Wellness, PLLC

Phone: 713-364-8171
Fax: 713-565-8462
Email: contact@tesserapsychiatry.com
Website: www.tesserapsychiatry.com

Please avoid including sensitive clinical information in ordinary email inquiries.

For additional information about your rights under the No Surprises Act, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

Updated October 2026.

Good Faith Estimate & Patient Rights

Your Right to Receive a Good Faith Estimate

Under the federal No Surprises Act, patients who do not have health insurance or who choose not to use their health insurance to pay for medical services have the right to receive a Good Faith Estimate of expected charges for non-emergency health care services.

A Good Faith Estimate provides information about the anticipated cost of care before services are received. It is not a bill, does not guarantee a particular treatment plan, and does not obligate a patient to receive services.

About TESSERA Psychiatry

TESSERA Psychiatry is a private-pay psychiatric practice providing virtual care to children, adolescents, and adults across the lifespan who are physically located in Texas or Florida at the time of their appointment.

TESSERA Psychiatry does not bill insurance directly. In some cases, upon request, a superbill may be provided for patients to submit to their insurance carrier for potential out-of-network reimbursement. Reimbursement is not guaranteed.

TESSERA Psychiatry does not prescribe controlled substances, including stimulant medications and benzodiazepines.

Services, Duration and Fees

- Adult Initial Psychiatric Evaluation - 60 minutes: $380

- Child & Adolescent Initial Psychiatric Evaluation - 75 minutes: $475

- Medication Management / Follow-Up - 30 minutes: $190

- Extended Follow-Up / Psychotherapy, with or without Medication Management - 45 minutes: $285

Fees are based on the services provided. The total anticipated cost of treatment depends on the nature of the services and the expected frequency and duration of appointments.

How Treatment Costs Are Estimated

The number and frequency of appointments vary according to individual clinical needs. Some patients may benefit from more frequent follow-up visits, while others may require appointments less often.

When recurring services can reasonably be anticipated, an individualized Good Faith Estimate may include the expected number, frequency, and cost of appointments over a period of up to 12 months.

The initial evaluation helps determine an appropriate treatment plan. If the anticipated course of treatment changes, an updated estimate will be provided when required.

Charges for separately scheduled services from other providers, such as laboratory testing, pharmacy services, or specialized assessments, may be additional. Patients may request separate estimates from those providers.

When You Will Receive a Good Faith Estimate

Eligible uninsured or self-pay patients, including parents or legally authorized representatives requesting care on behalf of a minor, may request a written Good Faith Estimate.

For appointments scheduled 3–9 business days in advance, an estimate will be provided within 1 business day after scheduling.

For appointments scheduled 10 or more business days in advance, an estimate will be provided within 3 business days after scheduling.

When an estimate is requested before scheduling, it will be provided within 3 business days of the request.

Your estimate will identify the services and expected charges reasonably anticipated based on the information available at the time it is prepared.

Your Rights if Your Bill Exceeds the Estimate

If you receive a bill from a provider that is at least $400 more than that provider's Good Faith Estimate, you may be eligible to dispute the charges through the federal patient-provider dispute resolution process.

Generally, disputes must be initiated within 120 calendar days of the date on the initial bill.

You may contact the provider to discuss the charges or request clarification. You may also seek an independent review through the federal dispute resolution process.

Initiating a dispute will not adversely affect the quality of care you receive.

Patients are encouraged to keep a copy of their written Good Faith Estimate for their records.

Questions or Requests

To request a Good Faith Estimate or ask questions about anticipated treatment costs, please contact:

TESSERA Psychiatry Garcia Psychiatry & Wellness, PLLC

Phone: 713-364-8171 Fax: 713-565-8462 Email: contact@tesserapsychiatry.com Website: www.tesserapsychiatry.com

Please avoid including sensitive clinical information in ordinary email inquiries.

For additional information about your rights under the No Surprises Act, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

Updated October 2026.

TESSERA Psychiatry
Garcia Psychiatry & Wellness, PLLC

Phone: 713-364-8171
Fax: 713-565-8462
Email: contact@tesserapsychiatry.com
Website: www.tesserapsychiatry.com