Good Faith Estimate & No Surprises Act Notice

Your Right to a Good Faith Estimate

You have the right to receive a “Good Faith Estimate” (GFE) explaining how much your therapy services are expected to cost.

Under the law, healthcare providers (including therapists) are required to give clients who do not have insurance or who are not using insurance (self-pay) an estimate of the expected charges for therapy services.

What This Means for You

• Before you begin therapy:
  You’ll receive a written Good Faith Estimate (GFE) outlining the expected cost of services. This will include the type of service, the session fee, and an estimate of costs over time.

• Timeframes:

  • If you schedule services at least 10 business days in advance, your GFE will be provided within 3 business days.

  • If you schedule 3–9 business days in advance, your GFE will be provided within 1 business day.

  • If you request an estimate without scheduling, it will be provided within 3 business days.

• Annual updates: For ongoing therapy, you’ll receive an updated estimate at least once every 12 months.

• Accessible formats: Your estimate can be provided in writing, electronically, or in another format upon request.

Important Notes

• The Good Faith Estimate is only an estimate. Actual costs may vary depending on your needs, frequency of sessions, and changes in your treatment plan.

• The GFE does not obligate you to receive services.

• If your bill is $400 or more above the Good Faith Estimate, you have the right to dispute the charges through a patient–provider dispute resolution process.

Adult Trauma and ADHD Solutions Fees

• Initial Intake Session (50 minutes): $250

• Individual Therapy Session (50 minutes): $200 per session

• Estimated Yearly Cost (weekly sessions for 12 months): $___ (This is only an example; your personalized GFE will reflect your actual plan.)

Your Rights

For questions or more information about your right to a Good Faith Estimate, visit: www.cms.gov/nosurprises

You may also contact me directly at:
📧 micah@adulttraumaandADHDsoutions.com
📞 [Your Phone Number]