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Good Faith Estimate

Good Faith Estimate – Psychotherapy

A Good Faith Estimate outlines the expenses that can be reasonably expected for the mental health/psychotherapy services provided to you. The estimate is based upon the information known at the time it is first created and does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. Should any information provided in the estimate change (increase in fee rates, agreement for frequency or type of services change for example) you will be provided with a good new faith estimate.

If you are billed for $400 or more than your Good Faith Estimate, you have a right to appeal (dispute) the bill in one of several ways.

  • You may contact me directly to let me know that the billed charges are higher than the Good Faith Estimate.
  • You can request that I update the bill to match the Good Faith Estimate, ask to negotiate the bill, or request information about the availability of financial assistance.
  • You may also 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 start the dispute process within 120 calendar days (about 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 be responsible for the amount provided on your Good Faith Estimate. If the agency disagrees with your dispute, you will have to pay the higher amount.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800)-368-1019.

Be sure to save a copy or picture of your Good Faith Estimate.