GOOD FAITH ESTIMATE:

This 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. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 368-1019. 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) 368-1019. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

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

Please be aware that treatment of mental health is a process that evolves over the course of a therapeutic relationship. As your therapist gets to know you and your concerns an individualized treatment plan will be collaboratively developed. We do our very best in an initial session to consider what treatment will entail, but this will naturally become more refined and adjusted over time.

As indicated on your GFE that you will receive from you provider, your estimate will adjust pending clinical need, safety, or experience of unpredictable life events. Estimate will also adjust if you request additional appointments beyond the usual agreed upon schedule. The totals listed on your Good Faith Estimate DO NOT account for no show/late, cancelation fees, bank charges, crisis sessions, non-therapeutic charges e.g. documentation fees, banking fees, court/litigation fees, or other financial arrangements based on a case-by-case basis. You are encouraged to carefully read the Practice Policies and Informed Consent for complete details regarding fee schedule and therapeutic process/expectations.

If you ever have questions regarding your treatment process, goals, progress, or charges, please immediately address with your provider.