Good Faith Estimate (GFE) Disclosure
 

Beginning January 1, 2022 it is legally required for all therapists and other health providers to provide all clients with a Good Faith Estimate (GFE). Below is NOT the actual Good Faith Estimate, but the disclosure of pertinent facts about the Good Faith Estimate. You will be provided your personalized Good Faith Estimate through your SimplePractice Client Portal.

  • I understand that the Good Faith Estimate (GFE) shows the costs of items and services that are reasonable expected for my healthcare needs for an item or service. The estimate is based on information known at the time the estimate was created and actual charges may differ.

  • My standard session fees are: $185 for 50 minutes, $220 for 60, $275 for 75 minutes

  • The Good Faith Estimate you receive will estimate the cost of weekly therapy over the course of 13, 26, & 52 weeks.

  • If you change session frequency, or there are changes in fee structures, you will be provided a new Good Faith Estimate.

  • I understand that the Good Faith Estimate (GFE) does not include any unknown or unexpected costs that may arise during treatment. There may be an additional items or services requested separately. I could be charged more if complications or special circumstances arise. If this happens, federal law allows me to dispute the bill. 

  • I understand that if I am billed more than this Good Faith Estimate (GFE), I have the right to dispute the bill. 

  • I understand that I may contact the provider listed to let them know the bill charges are higher than the Good Faith Estimate (GFE). 

  • I understand I can ask them to update the bill to match the Good Faith Estimate (GFE), ask to negotiate the bill, or ask if there is financial assistance available.

  • I understand that I may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If I choose to use the dispute resolution process, I must start the process within one hundred and twenty (120) calendar days of the date on the original bill. 

  • I understand that there is a $25 fee to use the dispute process. If the agency reviewing my dispute disagrees with me, I will have to pay the process on the Good Faith Estimate (GFE). If the agency disagrees with me and agrees with the provider, I will have to pay the higher rate.

  • I understand I may go on the website to learn more information and get a form to start the process: www.cms.gov/nosuprises or call Health & Human Services (800)368-1019.

  • I understand if I have questions or for more information about my right to a Good Faith Estimate (GFE) or dispute the process I may visit: www.cms.gov/nosuprises or call Health & Human Services (800)368-1019.

  • I understand that the Good Faith Estimate (GFE) is NOT A CONTRACT and does not require the uninsured or self-pay individual to obtain the items or services from any provider identified in the Good Faith Estimate (GFE). You are free to end therapy at any time and are not contracted for any number of sessions.