No Surprises Act: Good Faith Estimate Notice
Effective January 1, 2022 · Applies to all self-pay and uninsured clients
Under the No Surprises Act, you have the right to receive a written Good Faith Estimate explaining how much your health care will cost before you receive services.
What the No Surprises Act Requires
The No Surprises Act (Public Law 116-260) was enacted to protect patients from unexpected medical bills. For self-pay or uninsured clients at this practice, it requires that you receive a Good Faith Estimate (GFE) of expected charges before scheduled services begin.
This practice is a private-pay practice. All services are provided on a self-pay basis at a stated rate of $200 per session. No insurance billing is processed. The No Surprises Act’s GFE protections apply to all clients of this practice.
Your Right to a Good Faith Estimate
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs such as medical tests, prescription drugs, equipment, and hospital fees.
A Good Faith Estimate must be provided to you:
· At least 3 business days before a service scheduled at least 10 business days in advance
· At least 1 business day before a service scheduled at least 3 business days in advance
· Within 3 business days of your request, when a service is requested but not yet scheduled
What a Good Faith Estimate Includes
A Good Faith Estimate from this practice will include:
· The expected cost per session
· The estimated number of sessions in the treatment period
· The estimated total cost for the planned course of services
· The service codes (CPT codes) and diagnosis codes associated with the anticipated services
The estimate is based on clinically appropriate projections at the time of intake. It is not a contract. Actual treatment length may vary based on clinical presentation and individual progress. If the expected course of treatment changes materially, an updated estimate will be provided upon request.
How to Request a Good Faith Estimate
A Good Faith Estimate will be provided automatically before your first scheduled session. If you would like to request one at any time before or during treatment, you may do so by:
· Sending an email to: fmurad@muradcounseling.com
· Sending a message through the client portal at: felix-murad.clientsecure.me
Requests will be acknowledged within one business day. The written estimate will be delivered within the timeframes required under the act.
If Your Bill Exceeds the Good Faith Estimate
If you receive a bill that is $400 or more above the total in your Good Faith Estimate, you have the right to dispute that bill. The dispute process is administered by the U.S. Department of Health and Human Services (HHS).
To initiate a dispute, you must submit your dispute within 120 calendar days of the date on the bill. The HHS dispute resolution process will determine a final payment amount.
For more information on your rights or to initiate a dispute, visit: cms.gov/nosurprises or call 1-800-985-3059.
Keep a copy of your Good Faith Estimate as a reference when comparing it against any bill you receive.
Questions About This Notice
If you have questions about this notice, the Good Faith Estimate you receive, or your rights under the No Surprises Act, please contact:
Murad Counseling, PLLC · Felix Murad, M.Ed., LPC-S · fmurad@muradcounseling.com
Additional information about the No Surprises Act and patient rights is available at CMS.gov/nosurprises or by calling the CMS No Surprises Help Desk at 1-800-985-3059.