Notice of Good Faith Estimate

You have the right to receive a Good Faith Estimate explaining how much your medical and mental health care, including psychotherapy services, is expected to cost.

Under the No Surprises Act (42 U.S.C. § 300gg-111), health care providers are required to give uninsured or self-pay patients an estimate of the expected charges for non-emergency medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency health care services, including psychotherapy services. Your Good Faith Estimate will describe the expected costs of scheduled services. It is not a contract and does not require you to obtain the services. The actual services and charges may differ from the estimate if your needs or treatment plan change. Additionally, Good Faith Estimates typically do not include potential late cancellation or no-show fees.

You may request a Good Faith Estimate from your health care provider, or any other provider you choose, when services are scheduled or upon request at any time during treatment.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill through the U.S. Department of Health and Human Services (HHS). Please keep a copy or take a picture of your Good Faith Estimate for your records.

For questions or more information about your rights under the No Surprises Act, visit www.cms.gov/nosurprises or call (800) 985-3059.