Good Faith Estimate / No Surprises Act Notice
Effective Date: 29 May 2026
Your Right to Receive a Good Faith Estimate
Under the federal No Surprises Act, health care providers are required to give clients who are uninsured or choosing not to use insurance the opportunity to receive a Good Faith Estimate of the expected cost of services. This estimate explains how much your care may cost before you receive services. The Centers for Medicare & Medicaid Services explains that Good Faith Estimates apply to uninsured or self-pay individuals and should include expected charges for scheduled health care items or services.
You have the right to receive a Good Faith Estimate if:
You do not have health insurance.
You have health insurance but choose not to use it for services. (If/when applicable/allowable by insurance and the signed contract between Provider and Insurance Company)
You request an estimate before scheduling or receiving services.
You are paying privately/out of pocket for therapy services.
When You Will Receive a Good Faith Estimate
If you are uninsured or self-pay, you have the right to receive a Good Faith Estimate in writing before your first appointment or at any time upon request. Federal guidance states that if a service is scheduled at least 3 business days in advance, the estimate should generally be provided no later than 1 business day after scheduling; if a service is scheduled or requested at least 10 business days in advance, the estimate should generally be provided within 3 business days.
You may also request a Good Faith Estimate at any time.
What the Estimate Includes
Your Good Faith Estimate may include expected charges for therapy services, such as:
Initial intake session: [$___] per session
Individual therapy session: [$___] per session
Partnered systems / relationship / family therapy session: [$___] per session
Other services, if applicable: [$___]
Because therapy is individualized, the total cost of treatment will depend on your needs, goals, frequency of sessions, and the length of time you choose to participate in therapy. A Good Faith Estimate is based on information known at the time it is created and may change if your treatment needs, frequency of sessions, or requested services change.
Example of Estimated Costs
For example, if your session fee is [$1] and you attend weekly therapy for 12 weeks, your estimated total cost would be:
[$1] x 12 sessions = [$12]
If you attend therapy every other week for 12 sessions, your total cost would still depend on the number of sessions attended:
[$1] x 12 sessions = [$12]
This is only an estimate. You are not required to attend a specific number of sessions, and you may choose to stop therapy at any time, subject to the practice’s cancellation and financial policies.
The Good Faith Estimate Is Not a Contract
A Good Faith Estimate is not a contract and does not require you to receive services from this practice. CMS sample language explains that providers do not have to use a specific form as long as required information is included, and professional guidance notes that the estimate should make clear that the client is not obligated to receive services from the listed provider.
If Your Bill Is Higher Than Expected
If you receive a bill that is substantially higher than your Good Faith Estimate, you may have the right to dispute the bill through the federal Patient-Provider Dispute Resolution process. CMS describes this process as available to uninsured or self-pay individuals who receive a bill that is substantially in excess of the expected charges listed on the Good Faith Estimate.
You may contact the U.S. Centers for Medicare & Medicaid Services for more information about your rights under the No Surprises Act.
Questions or Requests
To request a Good Faith Estimate or ask questions about fees, private pay services, or billing, please contact:
Garis Counseling
Kody Garis, LPC, MCMHC
Email: kody@gariscounseling.com
Website: www.gariscounseling.com