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Good Faith Estimate Notice

1. Overview

Under federal law, including the No Surprises Act, you have the right to receive a Good Faith Estimate explaining the expected cost of your care.

This notice is provided to inform clients of their rights to receive a Good Faith Estimate for services when not using insurance or choosing not to use insurance benefits.

2. Client Rights and Key Information

Your Right to a Good Faith Estimate

If you are not using insurance or choose not to use your insurance benefits, you are considered a self pay client. As a self pay client, you have the right to receive a written Good Faith Estimate before services are provided, or at any time upon request.

A Good Faith Estimate describes the expected charges for items and services that are reasonably anticipated based on the information available at the time the estimate is created.

Important Information

  • A Good Faith Estimate is not a bill and is not a contract
  • It does not include unknown or unexpected costs that may arise during treatment
  • Actual services and charges may differ based on clinical needs and the course of care
  • Additional services may be recommended during treatment that are not included in the initial estimate
  • If needs change, an updated Good Faith Estimate may be provided

3. How to Request a Good Faith Estimate

You may request a Good Faith Estimate at any time before or during treatment.

Requests may be submitted using the contact information listed below.

4. Dispute Resolution and Complaints

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

You may contact the provider to discuss the bill, request that it be reviewed, or ask about available options.

You may also initiate a federal patient provider dispute resolution process through the U.S. Department of Health and Human Services. This process must be started within 120 calendar days of the date on the original bill. A $25 administrative fee applies.

For more information or to begin the process, visit:
https://www.cms.gov/nosurprises
or call (800) 985 3059.

5. Practice Information

Pattern Shift Counseling, PLLC
Jason Joseph, LPC (TX), LPC (OR), LMHC (WA), CPC (NV)
Telehealth counseling services
Email: jason@patternshiftcounseling.com
Phone: 214 600 4830

6. Legal References

This notice is provided in accordance with the No Surprises Act and its implementing regulations, including 45 CFR 149.610.

For additional information, visit:
https://www.cms.gov/nosurprises