Good Faith Estimate

Notice of Your Right to a Good Faith Estimate
Under the No Surprises Act

You have the right to receive a Good Faith Estimate (GFE) explaining how much your medical (including mental health) care will cost.

Under federal law, health care providers must provide clients who either don’t have insurance or aren’t using insurance with an estimate of expected charges for non-emergency medical services. Mental health care, including psychotherapy, falls under this umbrella.

You are entitled to:

• A written Good Faith Estimate at least 1 business day before your scheduled services.

• An estimate that includes all related costs (for medical care, this could include tests, medications, or equipment; for psychotherapy, this primarily includes session fees).

• A copy of your Good Faith Estimate to keep for your records.

• A dispute process if you receive a bill $400 or more above the estimated amount.

To learn more about your rights under the No Surprises Act, visit www.cms.gov/nosurprises or reach out to me via my secure contact form.

Sample Good Faith Estimate

Provided in accordance with the No Surprises Act (HR 133, Title 45 Section 149.610)

This sample is for demonstration only. Your personalized Good Faith Estimate may vary in format or details and will include your specific information and rates. You can always view my current fees on the Rates & Hours page.

Sample

Pursuant to the No Surprises Act (HR133, Title 45 Section 149.610), this form is used to provide current or prospective clients with a “Good Faith Estimate” (GFE) of expected charges for services to be provided.

CLIENT INFORMATION
Client Name:
Date of Birth:
Address:
Phone #:
Email:
Diagnosis Code(s) (if known):
Requested Services (Type and CPT Codes):

PROVIDER INFORMATION
Name: JoEllen Lange, LMFT
License #:
Address:
Phone #:
Tax ID# (if applicable):
NPI # (if applicable):

Estimated Cost of Services

Psychotherapy is a collaborative, individualized process, and the number of sessions can vary—different rhythms of care and unanticipated life events affect cost projection. This estimate is not a contract and does not commit you to a specific number of sessions. You may stop services at any time.

Session Type: Telehealth psychotherapy
Fee per Session: $___ (demonstrated as ‘Y’ below; see Rates & Hours for current rates)
Typical Duration: ___ minutes

Many clients begin with weekly sessions, though frequency may vary over time (e.g., biweekly, monthly, or as needed). Below is how the cost would be calculated based on frequency and duration:

• Weekly sessions for 3 months: 12 sessions × $Y = $yy

• Biweekly sessions for 3 months: 6 sessions × $Y = $yy

• Weekly sessions for 6 months: 24 sessions × $Y = $yy

• Weekly sessions for 12 months: 48 sessions × $Y = $yy

These are estimates, not commitments. Your actual costs may vary depending on your needs and goals. In addition, the GFE does not account for any vacations, holidays, emergencies, or sick time you or I might schedule or experience.

NOTE also that the GFE does not account for any late cancel or other fees you may incur (see my RATES policy).

You're welcome to request an updated GFE at any time.

Required Disclaimers

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs. It is based on information known at the time it was created.

• The estimate does not include unknown or unexpected costs that may arise during treatment. You may be charged more if special circumstances arise.

• This is not a contract, and does not commit you to obtaining any services listed.

• You are entitled to disagree with any recommendations made to you concerning your treatment, and you may discontinue treatment at any time

• You have the right to dispute a bill that is $400 or more above the estimate.

Dispute Process

If you receive a bill that is $400 or more above the amount listed in your Good Faith Estimate, you can

• Contact me to discuss or clarify the bill.

• Request that the bill be adjusted to match the estimate.

• Inquire about payment plans or financial assistance options.

• Start a dispute resolution process through the U.S. Department of Health and Human Services (HHS).

To begin the dispute process, you must do so within 120 calendar days of the original bill. The process includes a $25 administrative fee.

More information and the required forms can be found at www.cms.gov/nosurprises or by calling (800) 368-1019.