Good Faith Estimate Notice

You have the right to receive a Good Faith Estimate of the expected cost of your medical and mental health services.

• If you do not have insurance or choose not to use insurance, the Practice will provide an estimate of expected charges for scheduled, non-emergency services, including psychotherapy.

• You may request a Good Faith Estimate before scheduling services.

• If you receive a bill that is $400 or more higher than your Good Faith Estimate, you may have the right to dispute the bill.

• Please keep a copy of your Good Faith Estimate for your records.

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