Forms

Good Faith Estimate

You have the right to receive a “Good faith Estimate” explaining how much your medical care will cost

Effective January 1, 2022, a ruling went into effect, called the "No Surprises Act".  Under the law, health care providers need to give patients, who do not have insurance or who are not using insurance, an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs, like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your healthcare provider gives you a Good Faith Estimate, in writing, at least 1 business day before your medical service or item. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you received a bill that is at least $400.00 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 (800) 368-1019.

 If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

  • Authorization to Disclose Information Form

Note: To download Adobe Acrobat Reader for free, Click here.

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