Good Faith Estimate for Therapy Services
Date of Estimate: January 1, 20XX
Client Information:
Full Legal Name: John Doe
Chosen Name: Jack
Date of Birth: 01/01/1842
Mailing Address:
Email Address:
Services Requested:
Provider Name: Laura Becker, LMFT
Primary Service Scheduled: Individual Psychotherapy
Location of Service: Telehealth
Expected Frequency of Service: Weekly
Cost per Service: $XXX.XX per session
Total Sessions Expected: 24
Description/Notes: Regular, weekly psychotherapy sessions are $XXX.XX per
session for 24 weeks. Supplemental sessions may be requested
at additional cost.
Practice Information:
Name: CT Affirmative Therapy LLC
Address: XX XXXXXX Road, XXXXXXX, CT XXXX
Contact Person: Christine Corrigan, Practice Manager
Contact Phone: (860) 901-0647
Contact Email: [email protected]
NPI: 1871232884
Taxpayer Identification Number: XX-XXXXXXX
Total Estimated Cost for Six Months: $X,XXX.XX
Disclaimer: This Good Faith Estimate shows the costs of services that are reasonably expected for your health care needs for a service. The estimate is based on information known at the time the estimate was created, and does not include any unknown or unexpected costs that may arise during treatment.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional service costs are in addition to the Good Faith Estimate.
If your needs change during treatment, your provider should supply a new, updated Good Faith Estimate to reflect the changes to treatment, and the accompanying cost changes.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
The Good Faith Estimate is not a contract between provider and client and does not obligate or require the client to obtain any of the listed services from the provider.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 985-3059.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
Date of Estimate: January 1, 20XX
Client Information:
Full Legal Name: John Doe
Chosen Name: Jack
Date of Birth: 01/01/1842
Mailing Address:
Email Address:
Services Requested:
Provider Name: Laura Becker, LMFT
Primary Service Scheduled: Individual Psychotherapy
Location of Service: Telehealth
Expected Frequency of Service: Weekly
Cost per Service: $XXX.XX per session
Total Sessions Expected: 24
Description/Notes: Regular, weekly psychotherapy sessions are $XXX.XX per
session for 24 weeks. Supplemental sessions may be requested
at additional cost.
Practice Information:
Name: CT Affirmative Therapy LLC
Address: XX XXXXXX Road, XXXXXXX, CT XXXX
Contact Person: Christine Corrigan, Practice Manager
Contact Phone: (860) 901-0647
Contact Email: [email protected]
NPI: 1871232884
Taxpayer Identification Number: XX-XXXXXXX
Total Estimated Cost for Six Months: $X,XXX.XX
Disclaimer: This Good Faith Estimate shows the costs of services that are reasonably expected for your health care needs for a service. The estimate is based on information known at the time the estimate was created, and does not include any unknown or unexpected costs that may arise during treatment.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional service costs are in addition to the Good Faith Estimate.
If your needs change during treatment, your provider should supply a new, updated Good Faith Estimate to reflect the changes to treatment, and the accompanying cost changes.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
The Good Faith Estimate is not a contract between provider and client and does not obligate or require the client to obtain any of the listed services from the provider.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 985-3059.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
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