Good Faith Estimate Notice

[Practice Name] Effective Date: [Month Day, Year] Last Updated: [Month Day, Year]

Your Right to a Good Faith Estimate

Under the federal No Surprises Act, health care providers must give patients who are uninsured or who are not planning to use insurance ("self-pay") an estimate of expected charges for therapy services before those services begin.

This requirement applies to our licensed therapy services. It generally does not apply to our non-clinical coaching services, since coaching is not a health care service under this law — however, we provide transparent fee information for coaching as well (see Section 6 below).

1. Who This Applies To

You are entitled to a Good Faith Estimate (GFE) if you:

  • Do not have health insurance, or

  • Have health insurance but do not plan to submit a claim for these services (self-pay)

If you do plan to use insurance, your costs will instead depend on your insurance plan's benefits, deductible, and copay/coinsurance amounts — contact your insurer directly for those details.

2. What the Estimate Includes

Your Good Faith Estimate will show the expected costs of the therapy services reasonably anticipated for your care, including:

  • Session type (e.g., initial evaluation, individual therapy session)

  • Service/billing codes (CPT codes) reasonably expected to be used

  • Expected frequency and number of sessions, if a course of treatment is anticipated

  • Cost per session and estimated total cost

  • Name, NPI, and location of the provider(s) furnishing services

  • Any other providers or facilities expected to be involved, if applicable

Please note: Because therapy is an individualized process, the actual number of sessions you need may differ from the original estimate depending on your progress, goals, and clinical needs. If ongoing care is recommended beyond the original estimate, you will receive an updated Good Faith Estimate.

3. When You Will Receive It

We will provide your Good Faith Estimate:

Situation Timeline Service scheduled at least 10 business days in advance Within 3 business days of scheduling Service scheduled at least 3 business days in advance Within 1 business day of scheduling You request an estimate without scheduling Within 3 business days of your request

The estimate will be provided in writing (paper or electronic, per your preference) before your first appointment.

4. Requesting an Estimate

You may request a Good Faith Estimate at any time, even if you have not yet scheduled services, by contacting:

[Practice Name] [Email] [Phone]

5. Your Right to Dispute a Bill

If you receive a final bill that is substantially higher (generally, $400 or more above your Good Faith Estimate) for the same provider or facility, you have the right to dispute the bill.

You may start a dispute by contacting the U.S. Department of Health & Human Services (HHS) Patient-Provider Dispute Resolution process:

You must generally start the dispute process within 120 calendar days of the date on the original bill. Initiating a dispute does not affect your right to also pursue other legal options.

Keep a copy of your Good Faith Estimate for your records — you'll need it if you choose to dispute a bill.

6. Coaching Fees (Not Subject to the No Surprises Act)

Because coaching is a non-clinical service and not a form of health care under federal law, coaching engagements are not required to include a formal Good Faith Estimate. In the interest of transparency, we nonetheless provide clear, written fee information before any coaching engagement begins, including:

  • Session/package rate

  • Estimated frequency and duration of engagement

  • Cancellation and rescheduling terms

  • Any additional fees (materials, assessments, etc.)

This information will be provided in your coaching services agreement prior to your first session.

7. Good Faith Estimate — Sample Template

(For internal use: complete and provide a version of this to each self-pay/uninsured client before their first appointment.)

Good Faith Estimate of Expected Charges

Field Details Patient Name [Client Name] Date of Birth [DOB] Date Estimate Provided [Date] Provider Name [Clinician Name], [Credential] Provider NPI [NPI Number] Provider Tax ID [TIN] Practice Location [Address] Diagnosis (if applicable) [ICD-10 code and description, or "To be determined at initial evaluation"] Service Description [e.g., Individual Psychotherapy, 45–50 min] CPT/Service Code [e.g., 90834] Estimated Cost Per Session $[Amount] Estimated Number of Sessions [Number, or "Ongoing — reassessed every X sessions"] Estimated Total Cost $[Amount] Additional Providers Involved [None / List names, NPIs]

This is an estimate, not a bill or a contract. Actual services and charges may differ based on your individualized care needs. This estimate does not include costs for any unforeseen services that may arise during treatment. You have the right to a new Good Faith Estimate if your care plan changes. For questions about this estimate, or to dispute a bill that substantially exceeds it, see Sections 4 and 5 above.

8. Contact Us

[Practice Name] [Address] [Email] [Phone]