No Surprises Act —

Good Faith Estimate

Your Right to a Good Faith Estimate

Under the No Surprises Act, you have the right to receive a Good Faith Estimate of the expected cost of your care before your first appointment and upon request at any time.

What this means for you:

If you are uninsured, or if you choose not to use your insurance for therapy services, I am required by law to provide you with a written Good Faith Estimate of costs before your first scheduled service.

Your Good Faith Estimate will include the expected cost of services, including session fees and any other charges reasonably anticipated for your care. The estimate is based on information known at the time of scheduling and may be updated if your care needs change.

If you receive a bill that is $400 or more than your Good Faith Estimate, you have the right to dispute that bill. You may contact me directly to resolve any billing discrepancy. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS) within 120 days of the date on your bill.

For questions about your right to a Good Faith Estimate or to request one, please contact me at [your email] or [your phone number].

For more information, visit www.cms.gov/nosurprises.