Your Right to a Good Faith Estimate

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

Under the law, health care providers need to give patients who do not have insurance, or who are not using insurance, an estimate of the expected charges for medical services, including psychotherapy and psychiatric services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency health care services.

You can ask Terra Psychiatry, PLLC for a Good Faith Estimate before you schedule a service, or at any time during your care.

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.

How It Works

• When you schedule an appointment, or at any time upon request, we will provide you with a written Good Faith Estimate of expected charges

• The estimate will include the expected cost for services such as psychiatric evaluations, follow-up visits, and psychotherapy sessions

• The estimate does not include unknown or unexpected costs that may arise during treatment

• You may be charged more if complications or special circumstances occur, but federal law allows you to dispute the bill in that case

How to Dispute a Bill

If you are billed for more than your Good Faith Estimate, you have the right to dispute the bill.

• Contact me first to discuss the charges and request an updated bill

• You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS)

• You must start the dispute process within 120 calendar days of the date on the original bill

• There is a $25 fee to use the dispute process

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 985-3059.