“No Surprises” Act Notice

Good Faith Estimate Notice

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including mental health services.

• You have the right to receive a Good Faith Estimate explaining how much your counseling care will cost.

• You can ask for a Good Faith Estimate before you schedule a service or at any time during your care.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.