Good Faith Estimate

For patients who are uninsured or who are not using their insurance, health care providers are lawfully required to provide an estimate of the bill for medical services.

You are entitled to receive a “Good Faith Estimate” of what the charges could be for therapy services provided to you. While it is not possible for a therapist to know in advance how many sessions may be necessary or appropriate for a given person, this form will provide an estimate of the cost of services provided. Your total cost of services will depend upon the number of sessions you attend, the length of these sessions, your individual circumstances, and the type and amount of services that are provided to you. 

Once therapy commences, there may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in your good faith estimate. This estimate is not a contract and does not obligate you to obtain any services, nor does it include any services rendered to you that are not identified here.  

You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). 

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.