Good Faith Estimate

Client Full Name*

First NameLast Name

Name and Relationship to Client (if other than themselves)

This form is for individuals who are not enrolled in a Health Insurance Plan, are not covered under a Federal Health Care program, are enrolled but are not seeking to file a claim with their plan, or do not have a health insurance policy. Due to Section 2799B-6 of the Public Health Service Act, a good faith estimate must be provided within 3 business days upon request. This estimate is to ensure that you are understanding the agreement of a "Self Pay" client and the potential cost that it can incur.

The Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for services provided. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may accure for clinical reasons during your treatment (examples being: emergency therapy sessions, an increase in the frequency of sessions -- more sessions / week, crisis calls, etc). You could be charged more if a complication or special circumstances occurs.

If you are billed for more than this Good Faith Estimate, you have the right to inquire for the reason. If the charge is inappropriate or unlawful, you have the right to dispute the bill. You can do so by contacting the health care provider or facility listed to let them know know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match 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 US Department of Health & Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days of the date on the original bill. There is a $25.00 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on the Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or faculty, 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 1-800-985-3059.

Services Start Date*

Date

Therapist / Provider Name*

How many sessions will you have per month? *

HOW MANY SESSIONS PER MONTH (E.G. WEEKLY = 4 SESSIONS)

Agreed Upon Session Rate ($) per hour*

SELF-PAY SESSION COST

Estimated Total Cost (Year @ approx 50 weeks - not including holidays/weeks off or cancellations or change in frequency, which would decrease this cost) [** MULTIPLY SESSION RATE X 50 (WEEKS IN A YEAR) TO GET TOTAL COST ]*

Multiply Session Rate x's 50 (weeks in a year) = TOTAL COST

The estimated costs are valid for 12 months from the date of the Good Faith Estimate.

Signature*

Good Faith Estimate for Health Care Items & Services