As part of the No Surprises Act, you are entitled to receive a Good Faith Estimate detailing the expected charges for psychotherapy services. This estimate provides an overview of the potential costs based on the number of sessions, your unique needs, and the type of services provided. While it’s challenging to predict exactly how many therapy sessions may be necessary, this estimate gives a clear outline of potential fees. The actual cost will depend on factors such as the number of sessions attended and the specific treatment plan agreed upon with your therapist.

 

Please note that this estimate is not a binding contract and does not obligate you to receive services. It also does not guarantee a specific number of therapy sessions or predict the total cost, as this will vary depending on your progress and discussions with your therapist.

 

Provider Estimate

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The estimated charges below are based on the assumption that most patients attend one psychotherapy session per week, though this may vary depending on your specific needs. This estimate is valid for 12 months from the date of issuance.

 

Your Rights and Dispute Process

 

If the final bill exceeds the Good Faith Estimate, you have the right to dispute the charges. You may contact the health care provider or facility to negotiate the bill, request financial assistance, or initiate a dispute resolution process through the U.S. Department of Health and Human Services (HHS). This process must be started within 120 days of receiving the original bill, and there is a $25 fee to initiate it.

 

For more information, visit www.cms.gov/nosurprises or contact HHS at (800) 368-1019. Please keep a copy of this Good Faith Estimate for reference, especially if you’re billed more than $400 above the estimate.