Good Faith Estimate.

Your right to a Good Faith Estimate

Under the federal No Surprises Act, health care providers must give clients who are uninsured, or who are insured but choose not to use their insurance, an estimate of the expected charges for services. This applies to mental health care, and it applies here.

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

What the estimate includes

Your Good Faith Estimate will set out the expected charges for the services you are scheduled to receive, including the session fee, the expected frequency of sessions, and any other services reasonably expected to be provided alongside them.

Because therapy is ongoing rather than a single procedure, the estimate reflects a projected course of care based on what is known at the time it is written. The number of sessions you actually attend is always your decision, made with Amber as the work progresses.

When you will receive it

You will receive a Good Faith Estimate in writing, on paper or electronically, according to these timelines:

• If you schedule a service at least three business days in advance, you will receive the estimate within one business day of scheduling.
• If you schedule a service at least ten business days in advance, you will receive the estimate within three business days of scheduling.
• If you ask for an estimate before scheduling anything at all, you will receive it within three business days of your request.

You can request a Good Faith Estimate at any time, before scheduling and without obligation. Asking for one does not commit you to anything.

If your bill is higher than your estimate

If you receive a bill that is at least $400 more than your Good Faith Estimate for any single provider, you have the right to dispute it through the federal patient-provider dispute resolution process.

How to start a dispute

• You must begin the dispute process within 120 calendar days of the date on your bill.
• There is a fee to use the dispute process. If the reviewer decides in your favor, you pay the disputed provider the amount from the estimate rather than the billed amount, less that fee.
• Starting a dispute will not affect the care you receive here.

Where to learn more

For questions about your rights under the No Surprises Act, or to begin a dispute, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Keep your copy

Save a copy or picture of your Good Faith Estimate. You will need it if you ever want to compare it against a bill or begin a dispute.

Questions about fees

If you want to know what working together would cost before you schedule anything, ask. We will send you an estimate in writing.