Overview: 

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Effective January 1, 2022, a ruling went into effect called the “No Surprises Act,” which requires mental health practitioners to provide a “Good Faith Estimate” (GFE) about out-of-network care to any patient who is uninsured or who is insured but does not plan to use their insurance benefits to pay for health care items and/ or services. 

The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your mental 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 are entitled to receive this “Good Faith Estimate” of what the charges could be for treatment provided to you by your healthcare provider. While it is not possible for a provider to know, in advance, how many sessions of medication management or psychotherapy may be necessary or appropriate for a given person upon the initiation of treatment, this form provides an estimate of the cost of services provided at the initial consultation/new intake appointment. Your total cost of services going forward will depend upon the number and type of treatment sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.

You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate 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.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-877-696-6775.