GOOD FAITH ESTIMATE*

(January 1, 2022) Under Section 2799B-6 of the Public Health Service Act, healthcare providers are required to provide individuals who do not have health insurance or opt out of using their heath insurance, upon request or at the time of scheduling healthcare items and services, a “Good Faith Estimate” of expected charges.

Note: A Good Faith Estimate is intended for you to be aware of estimated fees. The estimate does NOT mean you need to make a commitment to the length or frequency of therapy sessions.

• 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 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.

• The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur.

• If you are billed at least $400 more than the sum provided in 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, visit www.cms.gov/nosurprises.

*Disclaimer: This legislation is still being interpreted. The above statement is an effort to provide those seeking mental health services what is currently believed to be important and required to share with both prospective and current clients. If new information involving this Act develops, this page will be updated to reflect those developments.