Good Faith Estimate

Good Faith Estimate
Note: "Good Faith Estimate" (GFE) of expected charges for services provided pursuant to the No Surprises Act. This federal act was instituted to avoid balance billing and surprise billing to recipients of healthcare services using out of network or self pay medical services. This document is a required effort to be in compliance with such regulations.
Client Name*

First NameLast Name
Street Address: *
Phone:   Area Code*   Phone Number*
DOB:   Date of Birth*
Email:   Email*
Date of Good Faith Estimate:   Today's date*
Office Locations:
- 27551 Cashford Circle #102, Wesley Chapel, FL 33544
- 18703 North Dale Mabry Lutz 33548
- Virtual Office
I understand that all counseling services will be rendered at one of the above locations.*
Therapist Name*

First NameLast Name
Client's Signature*

Clear
Date*

MonthDayYear
Date
DX CODE*
I confirm to have received a copy via email or hard copy of the “Good Faith Estimate”. *
Initials
Email for a copy of form to your inbox!*
example@example.com
Should be Empty: