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Notice of Your Right to a “Good Faith Estimate”

Under the federal No Surprises Act, healthcare providers are required to give patients who do not have insurance, or who choose not to use their insurance, an estimate of the expected charges for medical items and services.
  • 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 psychiatric evaluations, ongoing medication management, and psychotherapy.
  • You have the right to receive this estimate in writing at least 1 business day before your scheduled medical service or item. You can also ask our office, and any other provider you choose, for a Good Faith Estimate before you schedule an appointment.
  • You have the right to dispute your bill if you receive a final bill that is at least $400 more than your Good Faith Estimate.
  • Make sure to save a copy or picture of your Good Faith Estimate for your personal records.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

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What does this mean for your care at Guzman & Baker Behavioral Health Services?

Because psychiatric care is an ongoing process rather than a single procedure, estimating the exact number of sessions you will need over a full year can be difficult. Your treatment timeline will depend on your specific diagnosis and your personal goals. To ensure you are fully informed of your potential costs, we provide a structured fee schedule:
  1. Transparent Pricing: Our self-pay rates are fixed. You will always know the exact cost of an Initial Psychiatric Evaluation. We do not have hidden facility fees or surprise surcharges.
  2. Custom Estimates: When you establish care as a self-pay patient, we will provide you with a written Good Faith Estimate outlining the expected frequency of your visits (e.g., meeting every 4 weeks vs. every 3 months) and the estimated total cost for 12 months of standard care.
  3. Collaborative Changes: If your clinical needs change and require more frequent visits than originally estimated, your provider will discuss this with you and issue an updated Good Faith Estimate so you are never caught off guard.

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Example of What to Expect for a Good Faith Estimate

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Good Faith Estimate for Health Care Items and Services

Guzman & Baker Behavioral Health Services Provider: [Provider Name] Practice NPI: [Insert NPI] | Tax ID: [Insert TIN] Contact: [Insert Email/Phone] | Address: [Insert Business/Mailing Address]

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Patient Information

Patient Name: [Patient Full Name] Date of Birth: [MM/DD/YYYY] Patient Location (Telehealth): [KS / MO / CO] Date of Estimate: [Date document generated]

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Treatment Estimate

The following is an estimate of the total expected costs for your psychiatric care over a 12-month period. Because psychiatric treatment is highly individualized, your actual care may require more or fewer sessions than estimated below. This estimate is based on a standard treatment protocol for your presenting concerns. Primary Diagnosis Code (ICD-10): [Insert Code, e.g., F32.1 or Z03.89 for pending initial evaluation]
Service Description & CPT CodeExpected FrequencyRate per SessionEstimated Total Cost
Initial Psychiatric Evaluation (90791)1 session$[Rate]$[Total]
Routine Psychotherapy (90837)[e.g., 6 to 12] sessions$[Rate]$[Total]
Total 12-Month Estimate:$[Grand Total]
Disclaimer 1: This is only an estimate. The Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. Disclaimer 2: Additional recommended services. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged for additional items or services if your provider recommends them as part of your care (such as specialized laboratory testing or more frequent crisis-stabilization visits). Disclaimer 3: Your right to dispute. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
  • Dispute Threshold: There is a $400 threshold to dispute a bill. If your final billed charges exceed this Good Faith Estimate by $400 or more, you qualify to initiate the patient-provider dispute resolution process.
Disclaimer 4: Not a contract. This Good Faith Estimate is not a contract and does not require or obligate you to obtain the items or services from Guzman & Baker Behavioral Health Services or [Provider Name].