Your Right to Receive a Good Faith Estimate of Expected Charges

If you do not have health insurance or are not using insurance to pay for your care, you have the right to receive a Good Faith Estimate of expected charges.

• You can request a Good Faith Estimate before scheduling care. Your provider must give you a written estimate within 3 business days of your request.

• If you schedule care 3–9 business days in advance, your provider must give you a written Good Faith Estimate within 1 business day after scheduling.

• If you schedule care 10 or more business days in advance, your provider must give you a written Good Faith Estimate within 3 business days after scheduling.

• If your bill from a provider or facility is at least $400 more than the estimate from that provider or facility, you may dispute the bill through the federal patient-provider dispute resolution process.

• Save a copy or picture of your Good Faith Estimate and your bill.

As a solo psychotherapy practice, I provide Good Faith Estimates for the psychotherapy services I provide. I do not provide medical tests, prescriptions, or facility services.

If you are uninsured or are not using insurance to pay for your care, I will provide a written Good Faith Estimate within the timeframes described above and before your first appointment.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

If you are paying out of pocket or not using insurance, I will provide you with a written Good Faith Estimate before your first appointment.