Good Faith Estimate (No Surprises Act)

Under the law, health care providers are required to provide a Good Faith Estimate of expected charges to individuals who are not using insurance or who are self-paying for services.

You have the right to receive a Good Faith Estimate for the total expected cost of services, including psychotherapy sessions and any related services.

You may request a Good Faith Estimate before scheduling services or at any time during treatment.

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

To request a Good Faith Estimate or for more information, please contact:

Counseling with Heart, LLC

ellenb@counselingwithheartservices.com

(678) 842-4800

For questions or more information about your right to a Good Faith Estimate or the dispute process, visitwww.cms.gov/nosurprises or call (800) 985-3059.

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.

Keep a copy of your Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.