Good Faith Estimate for Services

The Carlile Therapy Group, PLLC

Your Rights and Protections Against Surprise Medical Bills

Under the federal No Surprises Act, effective January 1, 2022, you have the right to receive a Good Faith Estimate of expected charges for health care services, including mental health services, if you are uninsured, self-pay, or receiving services from an out-of-network provider and not using insurance to pay for those services.

What is a Good Faith Estimate?

A Good Faith Estimate (GFE) is an itemized written estimate of the expected cost of services we reasonably expect to provide based on the information available at the time the estimate is prepared. It includes charges for services we expect to provide and any other items or services reasonably anticipated to be part of your care.

This estimate is not a contract and the actual amount you are billed may differ based on factors such as changes in your treatment plan, the number of sessions attended, and other services you may receive.

When Will You Receive This Estimate?

You can request a Good Faith Estimate at any time, including before scheduling services. We will provide the written Good Faith Estimate:

• Before you schedule a service, upon request; or
• Within 1 business day after you schedule a service that is scheduled at least 3 business days in advance; or
• Within 3 business days after you schedule a service that is scheduled at least 10 business days in advance; or
• Within 3 business days after you request an estimate if requested before scheduling.

To provide the estimate promptly, we need your full name and date of birth. We cannot issue a Good Faith Estimate until this information is received.

How to Use This Estimate

A Good Faith Estimate helps you understand the expected cost of care and plan for the financial aspect of your treatment. The estimate is based on assumptions that could change over time as treatment needs change.

Your Rights Under Federal Law

Right to a Good Faith Estimate

You have the right to receive a Good Faith Estimate for the total expected cost of your scheduled services if you are an uninsured or self-pay individual, or if you are receiving care from an out-of-network provider and you are not submitting the charges to your insurer.

Disputing a Bill That Is Higher Than Your Estimate

If you receive a bill that is at least $400 more than the expected charges listed on your Good Faith Estimate for the same services, you may dispute the bill. To initiate the dispute process:

• Start the dispute process within 120 calendar days of the bill date; and
• Contact the U.S. Department of Health and Human Services (HHS) at 1-800-985-3059 or visit www.cms.gov/nosurprises for information on how to submit a dispute.

Save a copy or photo of your Good Faith Estimate and the bill you received - these are needed to support your dispute.

Additional Information & Contact Resources

For more information about the No Surprises Act and your rights:

• CMS No Surprises Act Consumer Website: www.cms.gov/nosurprises
• CMS Consumer Line: 1-800-985-3059

If you have questions or concerns about your Good Faith Estimate or the cost of your care, please contact our office - we are here to help you understand your estimate and answer your questions.