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Notice of
Good Faith Estimate

No Surprises Act

Title I of Division BB of the Consolidated Appropriations Act, 2021 (also known as the No Surprises Act) requires health care providers and health care facilities to inform individuals who are not enrolled in a health care plan or a Federal health care program, or not seeking to file a claim with their plan, both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.

If you don’t have insurance or are not using insurance to pay for your mental health care, you have the right to receive a “Good Faith Estimate” explaining the total expected costs that are reasonably expected for your healthcare.

  • You have a right to receive a Good Faith Estimate in writing at least 3 business days before your appointment. You can also ask your therapist for a Good Faith Estimate at any time before you schedule an item or service.
     

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

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

 

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

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