Your Right to a Good Faith Estimate

 

Under federal law (the No Surprises Act), you have the right to receive a Good Faith Estimate explaining how much your medical and mental health care will cost.

 

If you do not have insurance or choose not to use your insurance for services, you have the right to receive a written estimate of the expected charges for services before they are provided.

 

You can request a Good Faith Estimate at any time before scheduling services or after scheduling an appointment.

 

The Good Faith Estimate will include:

• A list of the services reasonably expected to be provided

• The estimated cost of those services

• Information about the provider and where services will be delivered

 

If you schedule a service at least 3 business days in advance, you will receive the estimate within the required timeframe.

 

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill.

 

For questions or to request a Good Faith Estimate, please

contact:

Revive Relationship Therapy
717-888-0173
rosie@revivert.com

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