Good Faith Estimate
Your Right to a Good Faith Estimate Under the No Surprises Act
Your Rights
Under the No Surprises Act (effective January 1, 2022), healthcare providers are required to give patients who don't have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy and psychiatric services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services. A Good Faith Estimate can cover up to 12 months of expected recurring services, such as ongoing medication management visits.
This Good Faith Estimate is not a contract and does not require you to obtain the services listed.
Estimated Service Costs
The following are estimated self-pay rates. Actual costs may vary based on clinical complexity.
| Service | Estimated Cost |
|---|---|
| Initial Psychiatric Evaluation (60 min) | $400 |
| Medication Management — Complex (45 min) | $325 |
| Medication Follow-Up — Standard (15–30 min) | $200 |
Important Information
- You can ask for a Good Faith Estimate before you schedule a service, or at any time during treatment.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- You must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process.
- Make sure to save a copy of your Good Faith Estimate.
- For questions or more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises or call 1-800-985-3059.
Request a Good Faith Estimate
To request a personalized Good Faith Estimate for your expected treatment, please contact us. We will provide a written estimate within one business day of your request, or within three business days of scheduling a service.