Good Faith Estimate Notice
Your rights under the No Surprises Act
Under the No Surprises Act, health care providers are required to provide clients who do not have insurance or who are not using insurance with a Good Faith Estimate of expected charges for medical services. This notice explains your rights.
What is a Good Faith Estimate?
You have the right to receive a written estimate of the expected cost of services before you begin treatment if you:
- Do not have health insurance, or
- Choose not to use your insurance benefits
The Good Faith Estimate outlines the anticipated cost of therapy services, including the expected number of sessions and the estimated total cost of care.
Please note that the estimate is based on information known at the time it is provided and is not a contract. The actual cost of services may differ depending on your individual treatment needs and circumstances.
When will I receive a Good Faith Estimate?
If you are paying out-of-pocket and schedule services with Era Psychotherapy, you will receive a Good Faith Estimate in writing before your first appointment, or upon request at any time.
You may also request an updated Good Faith Estimate if your treatment plan changes.
What if the final charges are higher than the estimate?
If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the charges.
You may initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS) within 120 calendar days (about 4 months) of the date on the original bill.
Information about the dispute resolution process is available at: www.cms.gov/nosurprises
Questions?
If you have questions about your Good Faith Estimate or your rights under the No Surprises Act, please contact us. You may also visit www.cms.gov/nosurprises for more information.
This notice is provided in compliance with the No Surprises Act and is intended for informational purposes only.