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Good Faith Estimate Notice (No Surprises Act)

Your Right to a Good Faith Estimate

You have the right to receive a Good Faith Estimate explaining how much your care will cost.

Under the No Surprises Act, healthcare providers are required to give patients who do not have insurance or who choose not to use insurance an estimate of expected charges for services. This applies to private pay speech therapy and wellness-based services.

A Good Faith Estimate outlines the anticipated cost of services related to your care when you are self-pay.

What This Means for You

  • You may request a written Good Faith Estimate before scheduling services or at any time.

  • The estimate will include the expected cost of evaluations, therapy sessions, or wellness services based on the recommended plan of care.

  • A Good Faith Estimate is not a bill and does not obligate you to receive services.

Dispute Resolution Rights

If you receive a bill that is $400 or more above your Good Faith Estimate, you have the right to dispute the charges.

You may initiate a dispute through the U.S. Department of Health and Human Services (HHS).

More information is available at:
www.cms.gov/nosurprises
or by calling 1-800-985-3059

Sample Private Pay Fees

(Fees are subject to change. A personalized Good Faith Estimate will be provided.)

  • Initial Speech / Communication Evaluation: $_____

  • Speech Therapy Session (___ minutes): $_____

  • Wellness / Communication Support Session: $_____

  • Consultation or Caregiver Training Session: $_____

Your individualized Good Faith Estimate will reflect the recommended frequency and duration of services.

Important Information

  • All services are provided on a private pay basis.

  • Insurance is not billed.

  • A physician referral or signature is not required for private pay or wellness services.

  • Clients are responsible for full payment at the time of service unless otherwise arranged.

  • Services may be classified as speech therapy or wellness-based services, depending on client goals and needs.

Questions

If you have questions about your Good Faith Estimate or private pay services, please contact me prior to scheduling.