GOOD FAITH ESTIMATE

You are entitled to receive a Good Faith Estimate explaining what the charges will be for your therapy treatment. While it is not possible for a therapist to know, in advance, how many therapy sessions may be necessary or appropriate for a given person, you are entitled to receive an estimate of the cost of services provided within a given estimated time. Your total cost of services will depend upon the number of therapy sessions you eventually have. You have the right to initiate a dispute resolution process if the actual amount charged to you exceeds the estimated charges stated in your Good Faith Estimate by $400.

You may contact your provider 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 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 health care provider or facility, you will have to pay the higher amount.

For questions or more information about your right to a Good Faith Estimate or the dispute resolution process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059.

The initiation of the patient-provider dispute resolution process will NOT adversely affect the quality of the services furnished to you.