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UPDATED May 22, 2023

Effective January 1, 2022

Surprise Billing Protection

The purpose of this notice is to let you know about your protections from unexpected medical bills. The No Surprises Act (“NSA”) refers to new legislation which became effective January 1, 2022. The intent of this Act is to protect consumers from “surprise” medical bills and balance billing, which is the practice of requiring a patient to make up (pay) costs not otherwise covered by their insurance company. Please consider if you would like to give up those protections and pay more for out-of-network care. You are getting receiving this reminder as I may be a provider outside of your health plan’s network. This means that I may not have an agreement with your plan. Getting care from me may cost you more. If your plan covers the item or service you’re getting, federal law protects you from higher bills. Ask your patient advocate if you need help knowing if these protections apply to you. Moreover, you have the right to receive a “Good Faith Estimate” explaining how much your medical care 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.


• 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. You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, a provided form will still display an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.


• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also 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 receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. 

There may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in this good faith estimate. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.


• Make sure to save a copy or picture of your Good Faith Estimate. 

You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).


For questions or more information about your right to a Good Faith Estimate or the dispute process, visit or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.

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