FOR PRIVATE PAY CLIENTS
Good Faith Estimate
As of January 1, 2022 there is a new law in place for providers called the "Good Faith Estimate.” A Good Faith Estimate is an estimate of the total estimated costs of non-emergency healthcare items or services. The Good Faith Estimate is a provision of the “No Surprise Act” Section 2799B-6 of the Public Health Service Act:
Intends to offer predictability & transparency in how much clients will be charged for healthcare services prior to their appointment.
Includes all regularly scheduled appointments (i.e. therapy sessions).
Does NOT include no-shows, late cancellations, or other services related to crisis care, which by definition are unexpected and cannot be predicted for the purpose of compiling a Good Faith Estimate in advance.
This may also include consultations with client collateral contacts, fees related to paperwork requests, and other legal and administrative fees related to client care, when such items are scheduled in advance.
You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a therapists to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.
There may be additional items or services recommended as part of your care that must be scheduled or requested separately and are not reflected a good faith estimate. 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 here.
OUR FEES
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).
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.