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Good Faith Estimate & No Surprises Act

Effective January 1, 2022, a ruling went into effect called the “No Surprises Act,” (H.R. 133) 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 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 psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person upon the initiation of psychotherapy, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy 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. 

Good Faith Estimate

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist.  You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

Good Faith Estimate Disclaimer:

This Good Faith Estimate shows 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.  Your provider may recommend additional services that are not reflected in this Good Faith Estimate.

The Good Faith Estimate is only an estimate—actual items/ service charges may differ.  The Good Faith Estimate does not include any unknown or unanticipated costs that may arise and are not reasonably expected during treatment due to unforeseen events.  You could be charged more if complications or special circumstances occur.  Other potential items and/ or services associated with therapy charges may include but is not limited to no-show/ late cancellation fee(s), record request(s), letter writing(s), legal fee(s)/ court attendance(s), professional collaboration(s), and in-between session supports).  These potential items/services and associated fee(s) are discussed further within the Informed Consent documentation and should these items/services be initiated, a new Good Faith Estimate will be provided.  The Good Faith Estimate does not obligate the client to obtain listed items or services.

You have a right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).

You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.

For questions or more information related to the Good Faith Estimate, visit www.cms.go/nosurprises or call (800) 368-1019.  Keep a copy of this Good Faith Estimate in a safe place.