No Surprise Act - Good Faith Estimate

Under the No Surprises Act, individuals who are uninsured or not using insurance have the right to receive a Good Faith Estimate of the expected costs for mental health services, including psychotherapy.

YOUR RIGHT TO A GOOD FAITH ESTIMATE

• You are entitled to a Good Faith Estimate for the total expected cost of non-emergency mental health services, such as psychotherapy.

• A Good Faith Estimate will include the expected charges for services provided by this practice.

• You can request a Good Faith Estimate before scheduling an appointment.

• The estimate will be provided in writing at least 1 business day before your scheduled session.

DISPUTING A BILL

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

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

DISCLAIMER

This notice is provided in compliance with the No Surprises Act to inform you of your rights to receive a Good Faith Estimate. It is not a guarantee of the final costs of services, which may vary depending on your specific needs.

For more information, visit www.cms.gov/nosurprises or call 800-985-3059.