“Right to receive a good faith estimate
Of expected charges”


(OMB Control Number: 0938-1401)

You have the right to receive a “Good Faith Estimate” explaining how much your services will cost. This will be provided by the specific therapist you choose and schedule an appointment with in advance of services.

Note: The expected cost of therapy is based on the clinician’s fee times the number of sessions needed. Your therapist will work with you throughout your treatment to determine how many sessions and/or services you need to receive the greatest benefit based on your diagnosis(es) or presenting clinical concerns. It is not possible nor therapeutically ethical to estimate the number of sessions needed upfront as ongoing variables contribute to that need and timeline. However, all payment is due at the time of service and all fees are discussed upfront. As a practice, we are committed to being transparent about fees and services so that clients do not experience financial surprises.

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 bill for medical services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

  • The explanation of my fees is stated on the Office Policies and Procedures document you will sign before scheduling a session with me. If you have any questions or concerns, please reach out to me directly.
  • According to the law, If you receive an unexpected 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 your provider.