Good Faith Estimate(GFE) Disclosure

• Beginning January 1, 2022 it is legally required for all therapists and other health providers to provide all clients with a Good Faith Estimate (GFE). Below is NOT the actual Good Faith Estimate, but the disclosure of pertinent facts about the Good Faith Estimate. You will be provided your personalized Good Faith Estimate on an individual basis.
• The Good Faith Estimate (GFE) shows the costs of items and services that are reasonable expected for my healthcare needs for an item or service. The estimate is based on information known at the time the estimate was created and actual charges may differ.
• My standard session fees are determined based on a 50-minute unit.
• Extended Sessions: will be prorated based on the above rate.
• The Good Faith Estimate can estimate the cost of therapy over the course of 13, 26, & 52 weeks.
• The Good Faith Estimate (GFE) does not include any unknown or unexpected costs that may arise during treatment. There may be an additional items or services requested separately. You could be charged more if complications or special circumstances arise. For example, extra sessions, phone conversations over 10 minutes in length, report writing. If this happens, federal law allows you to dispute the bill.
• If you are billed more than this Good Faith Estimate (GFE), you have the right to dispute the bill.
• You may contact the provider listed to let them know the bill charges are higher than the Good Faith Estimate (GFE).
• You can ask your provider to update the bill to match the Good Faith Estimate (GFE), 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 process within one hundred and twenty (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 disagrees, you will have to pay the process on the Good Faith Estimate (GFE). If the agency disagrees with you and agrees with the provider, you will have to pay the higher rate.
• If you have questions or for more information about your right to a Good Faith Estimate (GFE) or dispute the process you may visit: www.cms.gov/nosurprises or call Health & Human Services (800)368-1019.
• Good Faith Estimate (GFE) is NOT A CONTRACT and does not require the uninsured or self-pay individual to obtain the items or services from any provider identified in the Good Faith Estimate (GFE). You are free to end therapy at any time and are not contracted for any number of sessions.
• However, I do have a 48 hour cancellation policy, so if you cannot attend a session and do not give 48 hours notice you will be responsible for payment of that missed session (but not for any subsequent scheduled sessions).