STANDARD NOTICE — Good Faith Estimate

"Right to Receive a Good Faith Estimate of Expected Charges"

Under the No Surprises Act

You have the right to receive a "Good Faith Estimate" explaining how much your therapy or mental health services will cost.

Under the law, health care providers need to give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items and services, including outpatient mental health and counseling services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services, including individual therapy, couples/family therapy, psychological testing or assessment, and any other services offered by this practice.

Make sure your therapist gives you a Good Faith Estimate in writing at least 1 business day before your first appointment or service. You can also ask your therapist, or any other provider you choose, for a Good Faith Estimate before you schedule an appointment.

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.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

August Harbor Therapy
Claire Connolly, LICSW
1748 N Street NW, Washington, DC 20036
202-540-0147