Good Faith Estimate
Effective January 1, 2022, health care provides are required by the "No Surprises Act" to provide a "Good Faith Estimate" (GFE) to any patient who is uninsured and to those who are insured but do not wish to use their insurance benefits to pay for health care services.
This Good Faith Estimate shows the cost of attending therapy:
1. Every other week for one year (26 weeks)
2. Every week for one year (52 sessions)
This Good Faith Estimate is not intended to serve as a recommendation for treatment nor is it a prediction of the number of sessions you will need. The actual number of sessions that are appropriate for your specific needs will be determined by you in conjunction with your therapist and will be based on your needs as treatment progresses. You are entitled to attend therapy less frequently than your therapist recommends and you may discontinue treatment at any time.
Most clients attend one therapy session per week or one session every other week. However, the frequency of sessions that are appropriate for your needs may be more or less than this estimate. At the end of your first session, you and your therapist will determine what best fits your needs. You and your therapist will continually assess your needs and frequency during your treatment.
*Please note: using a provider that accepts your insurance benefits may reduce your cost of services.
Disclaimer: Our Good Faith Estimates show the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
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 have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 368-1019.
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.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
This Good Faith Estimate shows the cost of attending therapy:
1. Every other week for one year (26 weeks)
2. Every week for one year (52 sessions)
This Good Faith Estimate is not intended to serve as a recommendation for treatment nor is it a prediction of the number of sessions you will need. The actual number of sessions that are appropriate for your specific needs will be determined by you in conjunction with your therapist and will be based on your needs as treatment progresses. You are entitled to attend therapy less frequently than your therapist recommends and you may discontinue treatment at any time.
Most clients attend one therapy session per week or one session every other week. However, the frequency of sessions that are appropriate for your needs may be more or less than this estimate. At the end of your first session, you and your therapist will determine what best fits your needs. You and your therapist will continually assess your needs and frequency during your treatment.
*Please note: using a provider that accepts your insurance benefits may reduce your cost of services.
Disclaimer: Our Good Faith Estimates show the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
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 have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 368-1019.
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.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.