Good Faith Estimate

Under the law, health care providers are required to provide a Good Faith Estimate of expected charges to individuals who don't have health insurance or don't plan to use their insurance for services.

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You are entitled to receive a Good Faith Estimate upon your request, or when you schedule health care services. Your Good Faith Estimate covers the costs of any non-emergency items or services, including psychotherapy.  Your estimate will be reviewed with you annually and adjusted as necessary.

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Disclaimer: The Good Faith Estimate outlines the costs that are reasonably expected for the anticipated services for addressing your mental health care needs.

Your Good Faith Estimate is based on the information known at the time of the estimate, and does not include any unknown or unexpected costs that may come up during treatment. The actual services or charges may differ from the estimate.

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If you are billed at least $400 more than your Good Faith Estimate, you are legally allowed to dispute (appeal) the bill. You can do this by contacting your health care provider and/or starting a dispute resolution process with the U.S. Department of Health and Human Services (HHS).

There is a $25 fee to use the dispute process, and doing so will not negatively affect the quality of health care services provided to you.

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To learn more about the Good Faith Estimate and dispute process, visit

www.cms.gov/nosurprises or call CMS at 1-800-985-3059.

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Make sure to take a picture or save a copy of your estimate in a safe place.