Good Faith Estimate Notice

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You are entitled to receive a Good Faith Estimate of what the charges could be for mental health services provided to you. While it is not possible for a therapist to know in advance how many therapy sessions may be necessary or appropriate for a given person, the law requires health care providers to give clients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services (including psychotherapy services).

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You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service

You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).

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For questions or more information about your right to a Good Faith Estimate or the dispute resolution process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059.

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The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.