STANDARD NOTICE

“Right to Receive a Good Faith Estimate of Expected Charges” Under the “No Surprises Act”

Clients have a right to receive a “Good Faith Estimate” explaining how much their medical care will cost.

Under the No Surprises Act, health care providers need to provide patients who do not have insurance or who are not using insurance an estimate of the total cost for medical items and services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. Please note, I do not offer these types of services. I offer Individual and Couples Therapy only, either in person or via tele-mental health.

Health care providers should provide a Good Faith Estimate in writing at least one business day before a client’s medical service or item. Clients can also ask their health care provider for a Good Faith Estimate before they schedule an item or service.

I provide session fees verbally or in writing during my initial call or email with clients and/or in my Informed Consent and Financial Agreement, which clients must sign before their first session. When/if fees change, clients are notified at least 30 days in advance in writing.

If the client receives a bill that is at least $400 more than their Good Faith Estimate for a 12 month period, they may dispute the bill. You should never receive a bill from me that is more than the fees quoted to you in writing in my Financial Agreement and/or in the Notice of Fee Change Letter.

Clients should save a copy or picture of their Good Faith Estimate.

For questions or more information about client rights to a Good Faith Estimate, visit www.cms.gov/nosurprises, or email Becky Nguyen at becky@therapywithbecky.com