Good Faith Estimate

Your Right to a Good Faith Estimate

Under the federal No Surprises Act, you have the right to receive a Good Faith Estimate explaining how much your medical and mental health care will cost. Health care providers are required to give clients who do not have insurance, or who are not using insurance, an estimate of the expected charges for medical services, including psychotherapy.

Who Receives a Good Faith Estimate

You are entitled to a Good Faith Estimate ("GFE") if you are self-pay, meaning you do not plan to file a claim with your health insurance for the services you receive at Green-Oakes Psychological Services & Consulting. Many of my clients use out-of-network benefits and submit a superbill themselves; for billing purposes those clients are still considered self-pay and receive a GFE.

When You Will Receive It

• At the time of scheduling, if services are scheduled at least 3 business days in advance.
• Within 1 business day of scheduling, if services are scheduled 3-9 business days in advance.
• Within 3 business days of scheduling, if services are scheduled 10 or more business days in advance.
• Any time you ask for one, in writing or verbally.

What the Estimate Will Include

• Your name and date of birth.
• A description of the service (for example, individual psychotherapy).
• The applicable service codes (CPT) and diagnostic codes (ICD-10), to the extent known at the time.
• The expected charges per session.
• The provider's name, NPI, and Tax ID.
• The location where services will be provided (telehealth).
• A disclaimer that the estimate is only an estimate and that actual costs may differ.

Current Self-Pay Rates

The following rates are used to prepare your individualized estimate:

Rates are subject to change with reasonable notice. Your individualized estimate will reflect the rates in effect at the time of scheduling.

A Note on Estimating Therapy Length

Psychotherapy is collaborative and the number of sessions you may need is difficult to predict in advance. Your Good Faith Estimate will include a reasonable projection of expected sessions over a 12-month period based on the presenting concerns and typical course of care. It is an estimate, not a treatment plan or commitment, and we will revisit progress and goals together throughout our work.

Your Right to Dispute a Bill

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill through the federal Patient-Provider Dispute Resolution process.

• You must start the dispute process within 120 calendar days of the date on the original bill.
• There is a $25 fee to use the dispute process.
• If the agency reviewing your dispute agrees with you, you will pay the price on the Good Faith Estimate. If they disagree and side with the provider, you will pay the higher amount.
• Disputing a bill will not affect the quality of care you receive from me.

To learn more or start a dispute, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Keep a Copy

Make sure to save a copy of your Good Faith Estimate. You may need it if you are billed for more than the estimated amount.

Questions or Requests

To request a Good Faith Estimate or ask questions about this notice, please contact me at Greenoakespsych@gmail.com or available upon request.