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 health care 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 ask for 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 sbove your Good Faith Estimate, you have the right to dispute the bill.

• 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.

• I will give you a written Good Faith Estimate within one business day of scheduling your first appointment. If you ask for one, including by asking about cost before you schedule, I will give it to you within three business days of your request.

• You can receive your estimate on paper or electronically. I will provide it in an accessible format or in your language on request.

• The estimate lists my session fees and the total expected cost of your care, based on the plan of care we discuss together. For Couples Therapy Intensives, it also includes the deposit.

• I will tell you about your right to an estimate when you schedule or ask about cost.

  More Information

To learn more about your right to a Good Faith Estimate or how to dispute a bill, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.