Good Faith Estimate - The No Surprises Act

You are entitled to receive a “Good Faith Estimate” of what the charges could be per session for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, the GFE form provides an estimate of the cost of services rendered that are provided per session. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and/or amount of services that are provided to you. The estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified in the estimate.

Under Section 2799B-6 of the Public Health Service Act: You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. • 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 orservice. If you receive a bill that is at least $400 more than 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 or call 1. 800. 985. 3059