Your Right to a Good Faith Estimate
Template demonstration content. Illustrative, not legal advice.
Under the federal No Surprises Act, you have the right to receive a Good Faith Estimate that explains how much your care at Stillwater Psychiatric is expected to cost. This page describes that right and how to use it.
Who This Applies To
The Good Faith Estimate is for patients who are uninsured, or who are insured but choose not to use their insurance and pay on their own. If you plan to use insurance for your visit, this estimate process does not apply in the same way, and your coverage and cost share are handled through your health plan instead. The insurance plans we contract with are listed on our insurance page.
What a Good Faith Estimate Includes
You have the right to receive a Good Faith Estimate of the expected charges for the care you are scheduling, before you receive it. The estimate covers the items and services reasonably expected for that care. For an outpatient psychiatry practice, that typically includes:
- The initial psychiatric evaluation, which runs sixty to ninety minutes.
- Follow-up medication management visits.
- Where they apply, a course of treatment such as TMS or Spravato, described as a series of expected sessions.
The estimate is based on the information known at the time it is prepared. It does not include charges from outside providers, such as a laboratory or a separate clinician, who are not part of this practice. It is an estimate, not a guarantee, and your actual care may change based on what you and your prescriber decide together.
How to Request a Good Faith Estimate
You can ask for a Good Faith Estimate at any time, and we will also provide one when you schedule care.
- If you schedule a visit at least three business days in advance, you will receive the estimate in writing within one business day of scheduling.
- If you schedule at least ten business days in advance, you will receive it within three business days.
- You may also ask for an estimate before you schedule anything, and we will provide one within the timeframes the law requires.
To request an estimate, contact the front desk at (214) 555-0432 or email [address on file]. Make sure you receive the estimate in writing and keep a copy. You can also ask any question you have about the estimate before your visit.
If You Are Billed Substantially More Than Your Estimate
If you receive a bill that is at least $400 more than your Good Faith Estimate for any provider listed on that estimate, you may be able to dispute the bill through the federal patient-provider dispute resolution process.
- You generally must start the dispute within 120 calendar days of the date on your bill.
- There is a small administrative fee to use the process, and that fee may be reduced or waived if it would be a hardship.
- While the dispute is under review, the provider may not move the disputed bill into collections or charge late fees on it, and may not take or threaten retaliatory action.
Starting a dispute does not affect the quality of care you receive from this practice.
Where to Learn More
For questions about your rights under the No Surprises Act, or to start a patient-provider dispute, visit www.cms.gov/nosurprises or call 1-800-985-3059. You may also contact our front desk and we will help you understand your estimate and your options.
Keep a Copy
Keep a copy of any Good Faith Estimate you receive. If you need a new copy, contact the practice and we will provide one.
This page is template demonstration content prepared by DBJ Technologies for a fictional practice. It is illustrative and is not legal advice. A real practice should confirm current No Surprises Act requirements and have this language reviewed by qualified counsel before use.