Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges. This form may be used by the health care providers to inform individuals who are not enrolled in a plan or coverage or a Federal health care program (uninsured individuals), or individuals who are enrolled but not seeking to file a claim with their plan or coverage (self-pay individuals) of their right to a “Good Faith Estimate” to help them estimate the expected charges they may be billed for receiving certain health care items and services.

Notice of Right to Receive Good Faith Estimate You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost. Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided. This detail is offered on our Assignment of Benefits form at your first visit, OR it can be requested in advance.

• You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. You will have to ask the provider of those services/items- we can only provide costs associated with counseling sessions.
• If you schedule a health care item or service at least 3 business days in advance, your health care provider or facility can be expected to give you a Good Faith Estimate in writing within 1 business day after scheduling.
• If you schedule a health care item or service at least 10 business days in advance, your health care provider or facility can give you a Good Faith Estimate in writing within 3 business days after scheduling. This notice serves this purpose for walk-in scheduling.
• You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, you can expect that the healthcare provider or facility will give you a Good Faith Estimate in writing within 3 business days after you ask. If this does not happen, please let our Compliance Officer know.
• Make sure to save a copy or picture of your Good Faith Estimate and the bill.

If you are billed for $400 more than this Good Faith Estimate (GFE), you have the right to dispute the bill

You may contact the clinical therapist at the contact listed above to let them know the billed charges are at least $400 higher than the GFE. You can ask them to update the bill to match the GFE, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original 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 this GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to:
www.cms.gov/nosurprises or call CMS at 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059.

This GFE is not a contract. It does not oblige you to accept the services listed above.

Keep a copy of this Good Faith Estimate (GFE) in a safe place or take pictures of it. You may need it if you are billed for more than $400 than the estimate provided above.