New Client Forms
Good Faith Estimate Notice
Under a newly enacted law, clients who do not have insurance or are not using their insurance for services have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.
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 at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.
Additional Forms
Authorization to Exchange Information/Adult
Authorization to Exchange Information/Minor
Under a newly enacted law, clients who do not have insurance or are not using their insurance for services have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.
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 at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.
Additional Forms
Authorization to Exchange Information/Adult
Authorization to Exchange Information/Minor