Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your mental health care will cost.

This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to me when I do the estimate. If your needs change during treatment, I will provide a new, updated Good Faith Estimate to reflect the changes to treatment, and the accompanying cost changes. 

The Good Faith Estimate is not a contract between me as the provider and you as the client and does not obligate or require you to obtain any of the listed services from me. 

If you are billed for $400 more than this Good Faith Estimate (GFE), you have the right to dispute the bill within 120 days (~4 months) of the original bill.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. For more information, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059.