GOOD FAITH ESTIMATE

Your Right to Receive a Good Faith Estimate of Expected Charges

People without insurance and/or those who are paying out-of-pocket for therapy services have the right to receive a “Good Faith Estimate” explaining how much therapy will cost. The Good Faith Estimate is required by the “No Surprises” Act, meant to prevent unexpected medical bills. While the majority of this Act applies to emergency medical services and hospitals that employ out-of-network providers, some information applies to mental health therapists, as well. According to the “No Surprises” Act, it is important for you to know:

• 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 have the right to a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare 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.

• Make sure to save a copy or picture of your Good Faith Estimate as proof of this agreement.

The purpose of this document is to provide you with a Good Faith Estimate for your therapy. Grey Nelei Counseling will additionally provide this information to you in-writing at any time upon request.

Diagnosis of Mental Health Disorders

The existence of a mental health diagnosis is not a prerequisite for therapy at Grey Nelei Counseling, and our clinicians do not always engage in the diagnosis of mental health disorders in the course of treatment. It is important that you understand most insurance

companies require an official diagnosis of a mental health disorder to bill for therapy services. It is important that you know we will not diagnose anyone seeking our services without a diagnostic evaluation and discussion with you. Please speak with your individual therapist if you have any questions or concerns.

Good Faith Estimate for Self-pay Clients

Most clients receiving individual counseling at Grey Nelei Counseling should expect to pay $100 per service (“appointment” or “session”), due at the end of each scheduled

service. An invoice will be created and sent to you upon completion of service. Therefore, for example, if you attend:

• 10 therapy appointments, you can expect to pay $1000 in out-of-pocket costs

• 20 therapy appointments, you can expect to pay $2000 in out-of-pocket costs

The number of appointments will be determined on an ongoing basis between you and your clinician.

A reduced fee for some psychotherapy services may be available, if this is arranged with your individual therapist and is documented in writing.

The Good Faith Estimate does not include an estimate of fees for missed, cancelled, or rescheduled appointments.

You and your therapist will agree in writing to the charge for any additional services other than those discussed within this Good Faith Estimate. If you are charged for other services without having previously agreed to those services in writing, federal law allows you to dispute (appeal) the bill. Similarly, if your cost per session is higher than this Good Faith Estimate, you have the right to dispute the bill.

General Information to Note

You are not obligated to attend any number of sessions based on this Good Faith Estimate. You can always discuss the length of treatment; progress in treatment; and plans to end treatment with your therapist at any point. It is additionally important to understand that you are not required to seek mental health services at Grey Nelei Counseling. It may be more cost effective to work with an in-network provider. If you have insurance and you are

interested in working with an in-network provider at any time and for any reason, Grey Nelei Counseling will do our best to help facilitate that referral.

Dispute Resolution

You may contact Grey Nelei Counseling to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call HHS (800) 368-1019.