Good Faith Estimate

Under the Federal No Surprises Act (H.R. 133 – effective January 1, 2022), you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, you can expect your provider to discuss changes to your treatment plan with you. In addition to direct psychotherapy services and fees, you may incur additional fees for the following: late cancellation/no show fee, medical records request, completion of documents (FMLA, disability, summary letters, etc.), consultation (provider assistance or attendance at IEP meetings, coordination of care, etc.) or subpoena or request to testify. This estimate does not commit you to any payments or schedule of treatment; its intent is only to provide transparency in the therapy process. 

If you are billed for at least $400 more than this Good Faith Estimate, you have the right to dispute the bill. You may contact us to let us know the billed charges are higher than the Good Faith Estimate. You can ask us to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. Initiation of a dispute resolution process will not adversely affect the quality of the care you receive. Please keep a copy of your Good Faith Estimate in a safe place. 

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

*Disclaimer: This legislation is still being interpreted involving mental health professionals and the above statement is in effort to provide what is currently believed to be important and required to share with both prospective and current clients. This page may be updated as more information evolves involving this new statute.