Notice of Your Right to a Good Faith Estimate

As of January 1st, 2022, the Centers for Medicare and Medicaid Services (CMS) instigated a new Federal rule to protect patients from unexpected medical bills and to increase transparency between health care clinicians and patients.
This rule requires all medical and mental health clinicians (including LCSWs) to give a “good faith estimate” (GFE) to patients estimating the cost of services and how long services may last.
I am also required to inform you that I am an “out-of-network” provider meaning that I do not submit claims to insurance and do not get paid by insurers.

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.
• If there is a dispute about this estimate, you may contact the Department of Health and Human Services within 120 days of the service outlined in this estimate.

Should you have additional questions about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call the “No Surprises” Help Desk at 800-985-3059.

DISCLAIMER:

It is not possible for a mental health therapist to know in advance, how many sessions may be necessary or appropriate for a given client. Therefore, the GFE cost estimate is only an estimate; it isn’t an offer or contract for services, nor does it obligate you to receive services with our practice.

The frequency, length, and cost of treatment can be determined in collaboration with your therapist in line with your clinical needs and appropriate course of treatment. Please be aware that costs may change as treatment needs change, or services are added or ended, and that you have the right to decide when you wish to end treatment at any time.

In addition, the GFE does not include non-clinical services that you as the client can control in terms of limiting costs that occur outside of therapy appointments, including missed appointments/late cancellations, response to subpoenas, legal/court fees, requests for documentation, and/or representation at school meetings. These are omitted from the GFE as they are not typical services, and they are not eligible for reimbursement from insurance.