Good Faith Estimate Policy

ABOUT YOUR RIGHT TO RECEIVE A GOOD FAITH ESTIMATE
OF EXPECTED CHARGES

Under the law, as a health care provider, I will give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

This estimate is called a "Good Faith Estimate" and explains how much your Therapy, Consultation, Supervision, & Training services will cost. Here are a few key things you should know about your Good Faith Estimate:

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
You may ensure that I give you a Good Faith Estimate in writing at least 3 business days before your Therapy, Consultation, Supervision, & Training services or item. You can also ask me for a Good Faith Estimate prior to scheduling.
If you receive a bill that is $400 more than your Good Faith Estimate, you can dispute the bill.
It's recommended that you save a copy of your Good Faith Estimate for your records.

For further information, visit www.cms.gov/nosurprises or call 800-985-3059.

The included "Good Faith Estimate" language is a modification of the Centers for Medicare and Medicaid Services model notice.

https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Practice-Management/CMS-10791-1-Right-to-Receive-a-Good-Faith-Estimate-of-Expected-Charges-Notice.pdf