Good Faith Estimate Notice
Informing uninsured or self-pay clients with an upfront cost estimate before starting treatment.
You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.
Under the law, healthcare providers must provide patients who do not have insurance or are not using insurance with an estimate of the expected charges for medical services, including psychotherapy services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.
- You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a 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 www.cms.gov/nosurprises.
[Adapted from Blueprint.com forms. Information can be sent electronically via Blueprint.com for clients who schedule an appointment]
