Good Faith Estimate Notice

Jennifer Walker, LCSW is committed to transparency regarding the cost of services and compliance with the No Surprises Act.

Under the No Surprises Act, health care providers are required to provide uninsured and self-pay clients with a Good Faith Estimate of expected charges for health care services.

The Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs. The estimate is based on information known at the time it is created and does not include any unknown or unexpected costs that may arise during treatment. Actual charges may differ if your treatment needs change or if additional services become necessary.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill through the Patient-Provider Dispute Resolution Process established by the U.S. Department of Health and Human Services (HHS).

If you are billed more than your Good Faith Estimate, you may:

• Contact the provider to discuss the charges.
• Request an updated bill that reflects the Good Faith Estimate.
• Ask to negotiate the bill.
• Ask whether financial assistance is available.
• Initiate the federal Patient-Provider Dispute Resolution Process.

If you choose to use the dispute resolution process, you must start the process within 120 calendar days of receiving the original bill.

For the most current information about your rights under the No Surprises Act, including dispute resolution procedures and any applicable fees, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Please keep a copy of your Good Faith Estimate for your records. You may need it if you are billed a higher amount than expected.

This Good Faith Estimate is not a contract and does not require you to obtain services from this provider. Actual treatment recommendations, services provided, and associated charges may differ based on your individual needs and clinical circumstances.