Good Faith Estimate Notice

(No Surprises Act)

 

You have the right to receive a Good Faith Estimate explaining how much your medical and mental health services will cost.

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Under federal law, health care providers are required to give patients who do not have insurance, or who are choosing not to use insurance, an estimate of the expected charges for medical services, including psychotherapy and other mental health services.

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You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency services before they are provided. This includes psychotherapy, holistic services (if applicable), assessments, and any other services offered by our practice.

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You may request a Good Faith Estimate at any time—before scheduling, when considering treatment options, or even if you are already receiving services.

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If you receive a bill that is $400 or more than your Good Faith Estimate, you have the right to dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate for your records.

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For questions or more information about your right to a Good Faith Estimate, visit:
www.cms.gov/nosurprises