Good Faith Estimate Notice

Notice to Clients and Prospective Clients

Under the law, healthcare providers are required to give clients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

Your Rights:

• You have the right to receive a good faith estimate explaining the total expected cost of any non-emergency healthcare services, including psychotherapy.

• You can request a good faith estimate from your healthcare provider, or any other provider you choose, before you schedule a service or at any time during your treatment.

Disputing a Bill:

• Make sure to save a copy or picture of your good faith estimate for your records.

For questions or more information about your right to a good faith estimate, or how to dispute a bill, please refer to your estimate or visit www.cms.gov/nosurprises.

Quality Time Institute for Mental Health

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