Good Faith Estimate Notice

If utilizing private pay services, a Good Faith Estimate will be provided to you before starting therapy to give you a clear understanding of anticipated costs for mental health services, as required by the No Surprises Act. This estimate is not a contract and reflects my best effort to anticipate expenses, but actual costs can vary if treatment needs to be changed or unexpected services arise. A Good Faith Estimate shows the total expected cost of any non-emergency items or services. You may request a Good Faith Estimate in advance of an already scheduled health care service or before scheduling a service. Make sure to save a copy or picture of your Good Faith Estimate. You have the right to dispute bills that are $400 or more over this estimate. To read more about this or dispute a process, visit www.cms.gov/nosurprises or call 1-800-985-3059