Good Faith Estimate

Under the No Surprises Act, health care providers are required to inform clients who are uninsured or who choose not to use their insurance benefits that they have the right to receive a Good Faith Estimate of the expected cost of their services.

A Good Faith Estimate outlines the expected costs of the mental health services you may receive. The estimate is based on information available at the time it is provided and does not include any unexpected costs that may arise if your treatment needs change.

If you are paying for services yourself, you have the right to:

• Receive a Good Faith Estimate before your first appointment or upon request.

• Receive an updated estimate if your treatment plan or expected services change.

• Dispute your bill if you are charged substantially more than your Good Faith Estimate, as permitted under federal law.

If you have questions about your Good Faith Estimate or would like to request one, please contact me before your appointment.

For more information about your rights under the No Surprises Act, visit www.cms.gov/nosurprises