Notice · No Surprises Act
01 Your right to an estimate
You have the right to receive a Good Faith Estimate explaining how much your care will cost. Under the law, health care providers must give clients who don’t have insurance, or who are not using insurance, an estimate of the expected charges for services.
02 What’s included
The expected charges for psychotherapy, including the initial assessment
The diagnosis and service codes we expect to use, where known
The number of sessions we reasonably expect, based on your goals
03 When you’ll receive it
You can ask for a Good Faith Estimate before scheduling. Once a session is booked, you’ll receive it in writing at least one business day before your appointment — and you can request one at any time.
04 If your bill is higher
If you are billed $400 or more above your estimate, you can dispute the bill.
Keep a copy or picture of your Good Faith Estimate. You can start a dispute within 120 days of the date on your bill.
05 Learn more
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.
Example
What a Good Faith Estimate looks like
Your actual estimate is provided in writing before your first session and reviewed together whenever your plan changes.
Good Faith Estimate
Individual psychotherapy · Maya Ellison, LMFT
SAMPLE
Service
Fee
Est. sessions
Initial assessment (60 min)
$200
1
Psychotherapy (50 min)
$180
12–24
Estimated total (12 months)
$2,360 – $4,520
Estimates assume weekly to fortnightly sessions. Your plan may change, and you’ll receive an updated estimate if it does.