Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care services will cost you. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.
You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.
If you receive a bill that is more than your Good Faith Estimate, you can dispute the bill (see Disclaimer below):
This Good Faith Estimate shows the costs of items and services that are
reasonably expected for your health care needs for an item or service. The
estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs
that may arise during treatment. You could be charged more if complications or
special circumstances occur. If this happens, federal law allows you to dispute
(appeal) the bill.
If you are billed for more than this Good Faith Estimate, you have
the right to dispute the bill.
You may contact the health care provider or facility listed 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.
To learn more and get a form to start the process, go to
For questions or more information about your right to a Good Faith Estimate
or the dispute process, visit www.cms.gov/nosurprises.
Keep a copy of this Good Faith Estimate in a safe place or take
pictures of it. You may need it if you are billed a higher amount.
If you believe you’ve been wrongly billed, you may contact:
The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
The California Department of Managed Health Care at 1-888-466-2219 or visit https://dmhc.ca.gov/portals/0/healthcareincalifornia/factsheets/fsab72.pdf for more information about your rights under California law.
The California Department of Insurance at 1-800-927-4357 or visit https://www.insurance.ca.gov/01-consumers/110-health/60-resources/NoSupriseBills.cfm for more information about your rights under California law.