Notice of Right to Receive a Good Faith Estimate

Under the No Surprises Act, you have the right to receive a “Good Faith Estimate” explaining how much 

your health care will cost.  Under the law, health care providers need to provide patients who don’t have insurance or who self-pay for their services an estimate of the bill for health care items and services (including psychotherapy services). 

You have the right to receive a Good Faith Estimate for the total expected cost of your psychotherapy services. 

Ensure your healthcare provider provides you with a Good Faith Estimate in writing at least one business day before your services begin. You can also ask your clinician 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 or call the U.S. Department of Health and Human Services (HHS) at 

1-800-985-3059.