Pursuant to the No Surprises Act (HR133, Title 45 Section 149.610), this form is used to provide a current or prospective client with a “Good Faith Estimate” (GFE) of expected charges for services to be provided. Meaning… we don’t want you to be surprised with a bill larger than listed on our services page!
As a patient, you have the right to receive a Good Faith Estimate of the charges for psychotherapy services. This estimate is not a contract and does not obligate you to obtain any services from the provider listed. The fee for a 50 minute psychotherapy visit is listed on the website. You have the right to dispute a bill if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate. You are encouraged to speak with your provider at any time any questions you may have regarding your treatment plan or the information provided to you in this Good Faith Estimate.
If the amount charged to you is significantly higher than the estimated charges in your Good Faith Estimate, you have the right to the bill. This will not affect the quality of services provided to you. You can contact the healthcare provider to update the bill, negotiate the charges, or inquire about financial assistance. Alternatively, you can start a dispute resolution process with the U.S. Department of Health and Human Services within 120 calendar days of the original bill. Keep a copy of the Good Faith Estimate in case need it. For more information, visit www.cms.gov/nosur or call (800) 368-1019.