Good Faith Estimate
Your right to transparent, upfront cost information under the No Surprises Act
Your Right Under Federal Law
You have the right to receive a Good Faith Estimate of expected charges before receiving any scheduled health care service. This right is protected under the No Surprises Act (effective January 1, 2022).
Who This Applies To
This notice applies to patients who are:
- Uninsured (no health insurance coverage)
- Self-pay (choosing not to use insurance for a particular service)
- Requesting a Good Faith Estimate for any reason
What a Good Faith Estimate Includes
Your Good Faith Estimate will include expected charges for:
- The primary service (psychiatric evaluation, medication management, therapy)
- Any related services or items reasonably expected as part of your care
- Applicable diagnosis and procedure codes
- The name and location of the provider(s) involved
Current Self-Pay Rates
Washington (WA)
Wyoming (WY)
Texas (TX)
A superbill can be provided upon request for potential out-of-network reimbursement from your insurer.
Insured Patients (via Headway)
If you are using insurance through Headway, your cost will be limited to your applicable copay, coinsurance, or deductible as determined by your plan. Headway will provide a separate cost estimate based on your specific benefits before your appointment.
Your Dispute Rights
If you receive a bill that is above your Good Faith Estimate, you have the right to dispute the bill. For questions or to start the dispute process, contact the Centers for Medicare & Medicaid Services (CMS) at 1-800-985-3059 or visit cms.gov/nosurprises.
Request Your Good Faith Estimate
To request a written Good Faith Estimate before your scheduled appointment, please contact us at least 3 business days in advance: