Good Faith Estimate


Effective 1/1/2022, a law went into effect called, The No Surprise Act, which requires health care practitioners to provide a Good Faith Estimate of your out of network health care costs.

All self-pay clients who do not intend to seek insurance reimbursement OR who have no “out of network” benefits have the right to a Good Faith Estimate (GFE).

This GFE 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. The GFE does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur.

Federal law allows you to dispute (appeal) the bill if you receive charges in excess of your expectations. If you are billed for $400 or more than your GFE, 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 GFE. You can ask them to update the bill to match the GFE, 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 GFE. 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 https://www.cms.gov/nosurprises or call (800) 368-1019.

You will receive a GFE prior to the start of your treatment. Keep a copy of this GFE in a safe place or take pictures of it. You may need it if you are billed a higher amount.

This estimate is not a contract. You are not obligated to receive services at this facility or by this provider. Our office can provide you with alternative referrals at your request.

Below is a schedule of fees for our most commonly used services. You may be eligible for additional discounts.
90847: 50 Min Couples Session – $280
90837: 50 minute individual therapy session – $280
90853: Group Therapy- $90 per session/8 session Module commitment ($720 total per module)

https://www.cms.gov/nosurprises