No Surprise Act
Notice to Clients and Prospective Clients
Under Section 2799B-6 of the Public Health Service Act, health care providers need to give clients who don’t have insurance or who are not using insurance a “Good Faith Estimate” (GFE) of expected charges for medical services, including psychotherapy services.
The GFE shows the costs of items and services that are reasonably expected for services provided. The estimate is based on information known at the time the estimate was created.
You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service, or at any time during treatment.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
This estimate is not a contract. You are not obligated to receive services at this facility or by this provider. Our office can provide you alternative referrals at your request.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on the Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
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, or how to dispute a bill, see your Estimate or visit www.cms.gov/nosurprises.
*The maximum does not include late cancelation/no show fees, crisis sessions, non- therapeutic charges e.g. documentation fees, banking fees, court/litigation fees, anger management, life skill services, or other financial arrangements based on a case-by-case basis.
**THE ESTIMATE DOES NOT TAKE IN ACCOUNT FOR TRANSACTION FEES, SLIDING FEE BENEFITS AS THOSE BENEFITS ARE BASED ON THE CLIENT’S INCOME AND FALL UNDER "OTHER FINANCIAL ARANGEMENTS". ESTIMATE IS BASED ON FEES QUOTED AT TIME OF INITIAL CONTACT AND CONFIRMED IN CONSULTATION APPOINTMENT.