Your Right to a Good Faith Estimate (For Uninsured or Self-Pay Clients)

Under the No Surprises Act Effective January 1, 2022, a federal law called the No Surprises Act protects clients from unexpected medical bills. If you are uninsured or choose not to use your insurance benefits for my services, you have the right to receive a Good Faith Estimate of your expected costs.

What is a Good Faith Estimate?

A Good Faith Estimate is a clear summary of the expected cost of your mental health care. It shows the total estimated costs for items and services that are reasonably expected for your care. The estimate is based on the information known at the time it's created and is for your awareness only.

Please Note:

• A Good Faith Estimate is not a contract and does not obligate you to obtain services from me.

• It does not include any unknown or unexpected costs that may arise during treatment.

How to Get a Good Faith Estimate

You have the right to request a Good Faith Estimate at any time. I will provide you with an estimate both orally and in writing.

• Upon scheduling: If you schedule a session at least 3 business days in advance, I will provide you with a Good Faith Estimate within 1 business day of scheduling.

• Upon request: If you request an estimate without scheduling, I will provide one within 3 business days of your request.

Your Right to Dispute a Bill

If the final bill you receive is at least $400 more than the total estimated charges on your Good Faith Estimate, you have the right to dispute the bill.

To do so, you can:

1. Notify me that your bill is higher than your Good Faith Estimate and request an updated bill, a negotiated rate, or financial assistance.

2. Start a patient-provider dispute resolution process with the U.S. Department of Health and Human Services (HHS).

For more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 985-3059.