No Surprises Act

Under the No Surprises Act, health care providers are required to provide patients who do not have insurance or elect not to use insurance an estimate of the total potential charges for the expected medical services they will be provided. This is called the Good Faith Estimate.

This Good Faith Estimate (GFE) shows the costs of services that are reasonably expected for the anticipated services to address your mental health care needs. The estimate is based on the information known to us when we created this estimate. The GFE 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 there are any unexpected changes to your course of treatment, you will be provided an updated GFE. You may also request an updated GFE in writing at any time.

This GFE is not intended to serve as a recommendation for treatment. The number of sessions or visits that are appropriate in your case, and the estimated cost for those services, depends on your needs, the recommended treatment plan, and what you agree to in consultation with the psychologist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time. This 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 here. 

We welcome the chance to speak with you about any questions you may have regarding your treatment plan or the information provided to you in this GFE. If you receive a bill that is higher than the total on this GFE, you may contact the psychologist at the contact information listed below to let them know the billed charges are higher than the GFE. If you are billed for $400 or more (per provider) than this GFE, federal law grants you the right to appeal (dispute) the bill. You can ask the provider to update the bill to match the GFE, ask to negotiate the bill, or ask if there is financial assistance available.

You have the right to start a billing 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 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 pay the lower price on this GFE. If the agency disagrees with you and agrees with the health care provider, you will have to pay the higher amount. 

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