Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act

If you’re uninsured or you pay for health care bills yourself ("self-pay" - you don’t have your claims submitted to your health insurance plan), providers and facilities must provide you with an estimate of expected charges before you receive an item or service.  

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

Under this law, health and mental health care providers need to give clients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. 

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. 

Make sure your health or mental health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health or mental health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. 

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. 

Make sure to save a copy or picture of your Good Faith Estimate

***To best apply this, Circle City Counseling, LLC will estimate based on weekly therapy for the remainder of the calendar year to ensure the likely maximum out of pocket cost is communicated.  This does not affect the treatment decisions should a client and/or family be ready to reduce in frequency.***

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call HHS at (800) 368-1019.