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Good Faith Cost Estimate

Good Faith Cost Estimate for Mental Health Services

No Surprises Act

Under Section 2799B-6 of the Public Health Service Act, mental health providers are required to provide a good faith estimate of expected charges for services to clients who are not enrolled in a plan, coverage, or federal health care program or not seeking to file a claim with their plan or coverage both orally and in writing, upon request or at the time of scheduling mental health services.

Client's Information:

Therapist's Information:

Disclaimer: This Good Faith Estimate shows the costs of services that are reasonably expected for your mental health care. The estimate is based on information known at the time the estimate was created. This 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 estimate, you have the right to dispute the bill. You may contact the provider or facility listed on this form to let them know the billed charges are higher than the estimate. You can ask them to update the bill to match the 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 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 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 Keep a copy of this Good Faith Estimate in a safe place or take a picture of it. You may need it if you are billed a higher amount.