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Good Faith Estimate for Health Care Items and Services” Under the No Surprises Act

Dear Patient,

In compliance with the No Surprises Act that goes into effect January 1, 2022, all healthcare providers are required to notify patients of their Federal rights and protections against “surprise billing.”

This Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, if a patient is uninsured, or if a patient elects not to use their insurance.

Additionally, we are required to provide you with a Good Faith Estimate of the cost of services  It is difficult to determine the true length of treatment for mental health care, and each patient has a right to decide how long they would like to participate in mental health care. Therefore, you will be provided with a fee schedule for the services typically offered by your provider, and we will collaborate with you on a regular basis to determine how many sessions you may need.

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 for testing, expected number of sessions, and  prescription drugs. 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.

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


Any 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. It is a best advised estimate, but estimates may change over the course an assessment, therapy and the changing needs for testing or treatment. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during assessment/treatment.