Starting on January 1, 2022, the No Surprises Act1 (NSA) protects uninsured (or self-pay)
individuals from many unexpectedly high medical bills.

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Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance (otherwise known as self-pay) an estimate of the bill for medical items and services.

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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. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.

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This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

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• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.

• Make sure your healthcare provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your healthcare provider, 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 cms.gov/nosurprises or call 1-800-MEDICARE (1-800-633-4227).