No Surprises Act – Good Faith Estimate Notice

Your Rights and Protections Against Surprise Medical Bills

Under the No Surprises Act (effective January 1, 2022), you have the right to receive a Good Faith Estimate explaining the expected cost of your care.

What this means for you:

• You can request a written estimate of the total expected charges for non-emergency services before you schedule or receive them.

• This estimate will include costs for therapy sessions, assessments, and any other related services.

• You are not required to accept services based on the estimate, and you can use it to compare costs with other providers.

Your Good Faith Estimate will include:

• The type and frequency of services recommended

• The estimated cost per session and total projected cost

• Any additional fees that may apply

If you receive a bill that is at least $400 more than your Good Faith Estimate:

You have the right to dispute the bill. You can contact the provider to discuss the charges or initiate a dispute resolution process through the U.S. Department of Health & Human Services.

For questions or more information about your rights under the No Surprises Act:

Visit www.cms.gov/nosurprises or call 1‑800‑985‑3059.

Example Good Faith Estimate Statement for Therapy Services

(You can adapt this for your intake process)

Service: Individual Therapy (53 minutes)

Rate per session: $150

Frequency: Weekly sessions for 12 weeks

Estimated total: $1,800

This is only an estimate. Actual costs may vary depending on your needs and treatment plan.