Good Faith Estimate Notice

Under federal law, health care providers are required to give clients who do not have insurance, or who choose not to use insurance, an estimate of expected charges for medical services, including psychotherapy.

Your Rights

• You have the right to receive a Good Faith Estimate (GFE) of the total expected cost of non-emergency health care services, including psychotherapy.

• You can request a Good Faith Estimate before you schedule a service or at any time during your treatment.

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

• Be sure to keep a copy or photo of your Good Faith Estimate for your records.

How This Works at My Practice

• Therapy provided through this practice is private-pay only and is not billed to insurance.

• At the start of services (and upon request at any time), I will provide you with a Good Faith Estimate in writing.

• The estimate will outline session fees and the total expected cost of services, based on the plan of care we discuss together.

More Information

For more information about your right to a Good Faith Estimate, or how to dispute a bill, you can visit: www.cms.gov/nosurprises