Good Faith Estimate Notice

Your Right to Receive a "Good Faith Estimate"

Under the No Surprises Act, you have the right to receive a "Good Faith Estimate" explaining how much your therapy services will cost.

Health care providers are required to give patients who don't have insurance or who are not using insurance an estimate of the bill for health care items and services before those items or services are provided.

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Your Rights as an Uninsured or Self-Pay Client

As an uninsured or self-pay client, you have the right to receive a Good Faith Estimate for the total expected cost of any therapy services upon request or when scheduling services.

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Timing of Your Estimate

If you schedule a therapy appointment at least 3 business days in advance, we will provide your Good Faith Estimate in writing within 1 business day after scheduling.

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If you schedule a therapy appointment at least 10 business days in advance, we will provide your Good Faith Estimate in writing within 3 business days after scheduling.

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You may also request a Good Faith Estimate before scheduling an appointment. If you do, we will provide it in writing within 3 business days after your request.

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What Your Estimate Includes

Your Good Faith Estimate will include:

• Your name and date of birth

• A description of the therapy services to be provided

• An itemized list of expected services (such as individual therapy sessions, intake assessment, etc.)

• Expected charges for each service

• Your therapist's name, credentials, and National Provider Identifier (NPI)

• The office location where services will be provided 

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Important Disclaimers

This estimate is not a contract. You are not obligated to obtain services from Ampersand Counseling & Well-Being, PLLC .

This is only an estimate. Actual services and charges may differ from the Good Faith Estimate. The estimate is based on information reasonably known at the time it is created.

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Additional services may be recommended. There may be other services your therapist recommends during treatment that are not included in this estimate. These services would be scheduled separately and are not reflected in the original Good Faith Estimate.

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The number of sessions may vary. While most clients attend therapy sessions weekly, the frequency and total number of sessions appropriate for you may be more or less than initially estimated. Your total cost will depend on the number of sessions you attend, your individual circumstances, and the type and amount of services provided.

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How to Dispute a Bill

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

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Steps to Dispute

1. Contact us first. Let us know the billed charges are higher than your Good Faith Estimate. You can ask us to update the bill to match the estimate, negotiate the bill, or ask about financial assistance.

2. Start a dispute with HHS. If you choose to use the federal dispute resolution process, you must start the process within 120 calendar days of the date on your original bill.

3. **Pay the $25 fee.** There is a $25 fee to use the dispute process.

4. Submit your dispute online through the CMS website at www.cms.gov/nosurprises, or call HHS at (800) 368-1019.

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If the agency reviewing your dispute agrees with you, you will only have to pay the price on your Good Faith Estimate. If the agency disagrees, you will have to pay the higher amount

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Keep a copy of your Good Faith Estimate in a safe place. You may need it if you are billed a higher amount.

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Questions?

If you have questions about your Good Faith Estimate or our billing practices, please contact us:

Ampersand Counseling & Well-Being, PLLC
5225 Old Orchard Rd STE 24B
Skokie, IL 60077
847-868-2132
info@ampersandpractice.com

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You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan or the information provided in your Good Faith Estimate.