You Have the Right to a Good Faith Estimate of Expected Charges

NOTICE

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

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care 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.
• Make sure to save a copy or picture of your Good Faith Estimate.
• As described in the informed consent, you have the right to decide at any time not to receive therapy from me. You have the right to end therapy at any time without any moral, legal, or financial obligations other than those already accrued.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises

Though treatment length can vary depending on the needs of each couple and your goals, prior to your first session you will receive a general Good Faith Estimate of your expected charges. As we formulate goals and determine your session frequency, the Good Faith Estimate can be collaboratively amended to reflect your unique treatment.