GOOD FAITH ESTIMATE

Your Right to Receive a Good Faith Estimate

Under the federal No Surprises Act, individuals who do not have health insurance or who choose not to use their health insurance to pay for services generally have the right to receive a Good Faith Estimate explaining the expected cost of their care.

This includes eligible mental health and other professional services provided by Serenity Counseling Solutions, including private-pay psychotherapy and Family Consultation & Care Planning services.

When You Can Receive a Good Faith Estimate

If you are uninsured or plan to pay for services yourself without submitting them to insurance, you may receive a Good Faith Estimate of the expected charges for scheduled services.

Generally:

• If you schedule a service 3–9 business days in advance, the Good Faith Estimate must be provided within 1 business day after scheduling.

• If you schedule a service 10 or more business days in advance, the Good Faith Estimate must be provided within 3 business days after scheduling.

• You may also request a Good Faith Estimate before scheduling a service. Generally, the estimate must be provided within 3 business days of your request.

A Good Faith Estimate is not required for emergency services.

What the Estimate Includes

Your Good Faith Estimate will provide information about the expected charges for services reasonably anticipated based on the information available at the time the estimate is prepared.

The Good Faith Estimate is not a bill. The estimate may be updated if your treatment needs, frequency of services, anticipated services, or other circumstances change.

If Your Bill Is Higher Than Your Estimate

If you receive a bill from a provider that is at least $400 more than that provider's Good Faith Estimate, you may be eligible to dispute the bill through the federal patient-provider dispute resolution process.

Generally, a dispute must be initiated within 120 calendar days of the date on the initial bill.

Please keep a copy of your Good Faith Estimate so you can compare it with your bills.

For questions or more information about your right to a Good Faith Estimate, visit the Centers for Medicare & Medicaid Services — No Surprises Act or call the No Surprises Help Desk at 1-800-985-3059.