GOOD FAITH ESTIMATE for PRIVATE PAY CLIENTS:
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.
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. 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.
Accrual of multiple unpaid sessions is not the case scenario that the Good Faith Estimate scenario refers to, nor is it grounds to dispute your bill just because your bill for multiple sessions exceeds the estimate for one session. Under the No Surprises Act you have a right to dispute your bill if each individual session is being billed at a rate that exceeds the Good Faith Estimate for one session.
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/consumers or call 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.
Keep a copy of your Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
The Good Faith Estimate will be provided to you at the beginning of therapy, and is only provided to private pay clients. It is not a requirement, under the No Surprised Act, to provide a Good Faith Estimate to clients who will be using a third party insurance to pay for sessions.
Once your therapist agrees to provide therapy for you, you will then get a link to our secure, client portal area. Our clinic Intake Forms are now all electronic through the client portal, and this is where you will fill them out.
Please ask your therapist to send you the link to your client portal to fill out the Intake Forms there.
t is important to keep the link, and password to your client portal, for later if you ever need to update a card on file or, check the status of your billing. For Tele-mental Health sessions it is also important to keep the session link handy for future online tele-conferencing sessions.