Good Faith Estimate 

Your Rights and Protections Against Surprise Medical Bills

Under federal law, you have the right to receive clear, upfront information about the cost of your mental health care.  As a healthcare provider, I am required to provide uninsured and self-pay clients with a Good Faith Estimate of expected charges for services.

A Good Faith Estimate outlines the anticipated cost of therapy services prior to scheduling, or at any time you request one.

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Your Right to Receive a Good Faith Estimate

You have the right to:

• Receive a Good Faith Estimate (GFE) in writing at least 1 business day before your appointment if you are not using insurance.

• Request a Good Faith Estimate at any time, even if you haven’t scheduled yet.

• Receive an estimate including:

  • Type of service

  • Expected frequency of sessions

  • Provider information

  • Expected total cost over 12 months (or length of treatment if known)

The Good Faith Estimate is not a bill. It is designed to prevent surprise charges and help you understand what therapy may cost.

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If You Receive a Bill Higher Than Expected

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill.

You may:

• Contact me to discuss the difference

• Ask for the bill to be adjusted

• File a formal dispute with the U.S. Department of Health & Human Services (HHS)

To start a dispute, visit:
www.cms.gov/nosurprises