Under the No Surprises Act, which took effect on January 1, 2022, all self-pay clients are entitled to an estimate of the range of costs that is likely for most patients. A self-pay client is any client who either has no insurance coverage or does not intend to use their insurance for their treatment.

For new patients, treatment needs, diagnoses, service frequency, and anticipated treatment duration may not be fully known until after the initial evaluation and the early stages of treatment. Estimated costs are valid for 12 months from the date of the Good Faith Estimate unless your provider sends you an updated Estimate. Updated estimates are typically sent at the beginning of each calendar year.

The specific services and fees associated with your care will be provided in an individualized Good Faith Estimate along with other new client paperwork if an initial session is scheduled.

Disclaimer: A Good Faith Estimate shows the costs of services that are reasonably expected for the services to address your mental health care needs. The estimate is based on the information your provider had when they prepared it. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If anticipated treatment needs, service frequency, or fees change substantially, your provider may issue an updated Good Faith Estimate. If you are billed more than $400 above this Good Faith Estimate (GFE), you have the right to dispute the bill. You may contact your provider at the contact listed if the billed charges are at least $400 higher than the GFE. You can ask your provider to update the bill to match the GFE, negotiate the bill, or check for financial assistance. Federal law allows you to dispute (appeal) the bill. You may 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 initiate it within 120 calendar days (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. For more information about your right to a Good Faith Estimate and to get a form to start the Dispute Resolution Process, go to:

www.cms.gov/nosurprises or call CMS at 1-800-985-3059.

A GFE is not a contract. It does not obligate you to accept the services listed. Keep a copy of your individualized Good Faith Estimate, if provided, in a safe place or take pictures of it. You may need it if you are billed more than $400 than the estimate provided above. If you have questions about this estimate, please discuss them with your provider.