Good Faith Estimate

Your Right to Receive a Good Faith Estimate

Under the law, healthcare providers are required to provide individuals who do not have insurance or who are not using insurance with an estimate of the expected charges for healthcare services.

You have the right to receive a Good Faith Estimate explaining the expected cost of psychotherapy services.

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

The Good Faith Estimate outlines the anticipated costs of services based on the information known at the time it is provided. Actual charges may vary if treatment needs change, additional services are recommended, or circumstances arise that could not reasonably have been anticipated.

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

You may save a copy or take a photo of your Good Faith Estimate for your records.

For questions or more information about your right to a Good Faith Estimate, visit:

https://www.cms.gov/nosurprises

Contact

If you have questions about Good Faith Estimates or psychotherapy fees, please contact:

Shai I. Larsen, Registered Associate Marriage and Family Therapist #163073

Supervised by Dylan Cimbura-Hernandez, Licensed Marriage and Family Therapist #120829

Email: shai@humboldttherapy.com

Phone: (707) 335-9521

Website: www.shailarsentherapy.com