Notice of Right to Receive a Good Faith Estimate (No Surprises Act)

If you do not have insurance/choose not to use insurance/are receiving services not covered by insurance, then you have the right to receive a Good Faith Estimate (GFE) explaining the expected cost of your evaluation or therapy services.

You can request a Good Faith Estimate before scheduling, or you will automatically receive one after scheduling:

• If your first appointment is more than 10 business days away: you’ll receive your estimate within 3 business days of scheduling.

• If your first appointment is between 3 and 10 business days away: you’ll receive your estimate within 1 business day of scheduling.

• If you ask for an estimate before scheduling: you’ll receive it within 3 business days of your request.

Your Good Faith Estimate will describe the type of service(s), the expected number of sessions (if known), the fee per session, and the total estimated cost for the time period covered by the estimate.

Please keep a copy of your estimate for your records. It is not a bill—actual costs may be different if your needs or the length of treatment change. A Good Faith Estimate does not require you to receive services from me.

If your bill is $400 or more than your Good Faith Estimate, you have the right to dispute the charges. You can first contact me to discuss the difference, and if needed, you may use the patient–provider dispute resolution process.

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