Right to Receive a Good Faith Estimate of Expected Charges

Under Section 2799B-6 of the Public Health Service Act, effective on January 1, 2022, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges. You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person upon the initiation of psychotherapy, this form provides a rough estimate of the cost of services provided.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate is only an estimate – actual items/service charges may differ. The Good Faith Estimate does not include any unknown or unanticipated costs that may arise or are not reasonably expected during treatment due to unforeseen events. You could be charged more if complications or special circumstances occur. Other potential items and/or services associated with therapy charges may include, but are not limited to, no show/late cancellation fee(s), record request(s), letter writing(s), and legal fee(s). The Good Faith Estimate does not obligate the patient to obtain listed items or services.

Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, therapist availability, ongoing life challenges, the nature of your specific challenges and how you address them, personal finances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified. You and your therapist will continually assess the appropriate frequency of therapy and will work together to determine when you have met your goals and are ready for discharge and/or a new “Good Faith Estimate” will be issued should the frequency of session(s) or needs change. As related, you may request a new Good Faith Estimate at any time in writing during your treatment.

The Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

● You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
● Make sure your health care provider gives you a Good Faith Estimate before you schedule an item or service.
● If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
● Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, call (800) 368-1019 or visit www.cms.gov/nosurprises