Beginning 01/01/2022, under section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to provide a Good Faith Estimate of expected charges for items and services to individuals who are not enrolled in a plan or coverage or a Federal Health Care Program, or not seeking to file a claim with their plan or coverage both orally and in writing, upon request or at the time of scheduling health care items or services.

If you wish to request a Good Faith Estimate be provided to you and you are a private paying client, then please reach out to your clinician to complete the request

The Good Faith Estimate attempts to clarify potential health care costs in an easy-to-understand way for clients to be able to appropriately plan and budget for longer term financial stability. Given the nature of therapy services, typically exact estimates are difficult to predict due to not knowing severity of symptoms, recommended frequency of services, length of time of services, and any other variables. Your clinician will work with you to obtain the best estimate based on your individual needs and update it as required by law.

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 800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place.

For any questions or concerns, please see your clinician.