In compliance with federal regulations mental health providers are required to give clients a Good Faith Estimate of expected costs for services. As a client you will receive a notification with information intended to meet these requirements. Please let me know if you have any questions or concerns about this information before we begin services.
A Good Faith Estimate is not a contract and does not require the client to obtain the items or services from any providers or facility identified in the good faith estimate. The information provided is only an estimate and actual items, services, or charges may differ. Additional items or services recommended in the course of care that must be scheduled or requested separately may not be reflected in this Good Faith Estimate.
Dispute Process: You have the right to initiate a patient-provider dispute resolution process if the actual billed charges substantially exceed the expected charges included in the Good Faith Estimate. Initiation of a patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to the patient. You may contact the health care provider or facility listed above 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 mental health provider or facility, you will have to pay the higher amount. To get a form to start the process, or for more information about your right to a Good Faith Estimate visit http://www.cms.gov/nosurprises or call 1-877-696-6775.
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