Good Faith Estimate Notice

Under the No Surprises Act, individuals who do not have health insurance or who choose not to use their insurance to pay for health care services have the right to receive a Good Faith Estimate of expected charges.

You have the right to receive a Good Faith Estimate for the expected cost of your mental health services.

• You may request a Good Faith Estimate before scheduling services.

• If you schedule services at least 3 business days in advance, you will generally receive a written Good Faith Estimate of the expected charges for services provided by this practice.

• Your Good Faith Estimate will identify the services reasonably expected to be provided and the estimated charges associated with those services.

• A Good Faith Estimate is an estimate of expected charges and is not a guarantee of the services you will receive or the total amount you will ultimately be charged. Your actual treatment needs, frequency of appointments, and length of treatment may vary.

• If your actual bill from this practice is at least $400 more than your Good Faith Estimate, you may be eligible to dispute the bill through the federal Patient-Provider Dispute Resolution process. Additional eligibility requirements apply.

• Please keep a copy of your Good Faith Estimate and compare it with your bill.

For more information about your rights under the No Surprises Act and Good Faith Estimates, visit the Centers for Medicare & Medicaid Services (CMS): www.cms.gov/nosurprises.