Good Faith Estimate

YOU HAVE THE RIGHT TO RECEIVE A “GOOD FAITH ESTIMATE” EXPLAINING HOW MUCH YOUR MENTAL HEALTH CARE WILL COST

Under the law, health care providers are required to give clients who do not have insurance or are not using insurance an estimate of the expected charges for medical services, including mental health services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency services. This includes the cost of psychotherapy sessions, evaluations, and any related services.

You have the right to receive your Good Faith Estimate in writing at least 1 business day before your scheduled service. You can also request an estimate before scheduling.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you may have the right to dispute the bill.

Make sure to save a copy or photo of your Good Faith Estimate for your records.

If you think you’ve been wrongly billed or want more information:

• Contact Self Aligned Therapy, PLLC directly.

• Or call the Colorado Division of Insurance at 303-894-7490 or 1-800-930-3745.

• For more details, visit www.cms.gov/nosurprises.