No Surprises Act Notice: Your right to a “Good Faith Estimate”

Federal law gives every client the right to receive a Good Faith Estimate” that gives you an

estimate of how much your treatment is likely to cost at our office.

Under federal law, healthcare providers are required to give patients who do not have or do not

choose to use their insurance coverage, an estimate of the cost for treatment and services.

☼ You should receive a Good Faith Estimate for the total expected cost of non-emergency

items or services, including related costs like tests, counseling or assessment fees and

other costs related to your services at our office.

☼ Ask your health care provider to give you a Good Faith Estimate in writing at least 1

business day before your first appointment. You can also ask your healthcare provider,

and your counselor for a Good Faith Estimate before you schedule an item or service.

☼ If you receive a bill that is $400 more than the Good Faith Estimate, you may dispute the

bill.

☼ Make sure to save a copy of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/.