Good Faith Estimate

Effective January 1, 2022, a ruling went into effect called the “No Surprises Act”, which requires mental health practitioners to provide a “Good Faith Estimate” (GFE) to any patient who is uninsured or who is insured but does not plan to use their insurance benefits to pay for health care items and/ or services. 

The Good Faith Estimate works to show the cost of items and services that are expected for your mental health care needs. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment.

You are entitled to receive a “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 985-3059.