Good Faith Estimate Notice

You have the right to receive a “Good Faith Estimate” explaining how much your medical or mental health care may cost.

Under federal law, health care providers are required to provide a Good Faith Estimate of expected charges to clients who do not have insurance or who are not using insurance benefits.

If you are a self-pay client, you may request a written Good Faith Estimate before scheduling services or at any time during treatment.

The estimate will include:

• The cost of each session

• The expected frequency of services (if known)

• An estimate of total costs over time

Please note that the estimate is based on information available at the time and actual services may vary depending on your needs.

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

For more information about your rights, visit:

www.cms.gov/nosurprises

If you would like to request a Good Faith Estimate, please contact me directly.