No Surprises Act Notice

Your Right to Receive a “Good Faith Estimate” of Expected Charges

Under the No Surprises Act (Section 2799B-6 of the Public Health Service Act), health care providers are required to give uninsured and self-pay clients an estimate of expected charges for medical and mental health services.

What is a Good Faith Estimate (GFE)?

You have the right to receive a Good Faith Estimate for the total expected cost of non-emergency services, including therapy sessions, assessments, and other services.

This estimate will include:

• The number of expected sessions (if known)

• The cost per session

• Any anticipated additional fees (e.g., reports, consultation, etc.)

When Will I Receive It?

You will receive your Good Faith Estimate in writing:

• At least 1 business day before your first scheduled service, or

• Upon request, even if you haven’t scheduled yet.

What If the Actual Cost Is Higher?

If you are billed $400 or more above the listed estimate, you may have the right to dispute the bill through the U.S. Department of Health & Human Services (HHS).

To dispute a bill, you must:

• Have a copy or picture of your Good Faith Estimate

• File your dispute within 120 days of receiving the bill

• Pay a small fee (currently $25) to initiate the dispute process

For More Information:

Visit www.cms.gov/nosurprises
Or call 1-800-985-3059

You can also contact me directly at teri@terimurphycounseling.com to request your personalized Good Faith Estimate.