Notice of Your Right to a Good Faith Estimate.

Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate explaining how much your medical care will cost.

A Note on the Length of Treatment:Estimating the exact length of therapy up front can be challenging, as it depends heavily on your unique goals, personal circumstances, schedule, and ongoing progress. Treatment length is an ongoing, collaborative discussion between you and your therapist. Ultimately, as the client, you always maintain the right to decide when to conclude your therapy services.

Key Protections of the No Surprises Act:

• Get an Estimate for Total Costs: 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 like medical tests, prescription drugs, equipment, and hospital fees.

• Receive it in Writing: Make sure your healthcare provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

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

• Keep a Copy: Make sure to save a copy or picture of your Good Faith Estimate.

Questions or Requesting an Estimate?

If you have questions about your right to a Good Faith Estimate, or if you would like to formally request an estimate prior to scheduling an initial consultation, please contact:

• Practice Name: Fieldwork Counseling, LLC

• Contact Email: hello@fieldworkcounseling.com

• Phone/Text: 678-679-9805

For more information about your right to a Good Faith Estimate under federal law, visit www.cms.gov/nosurprises or call 1-800-985-3059.