Good Faith Estimate & Coverage Disclosure

In Compliance with the No Surprises Act (Effective January 1, 2022)

Your Rights Under Federal Law

You have the right to receive a Good Faith Estimate (GFE) explaining the expected costs of your mental health care services, particularly if you are uninsured or choose to self-pay. This document is designed to increase transparency and help you make informed decisions about your care. You are not required to proceed with services and may seek care elsewhere. This estimate does not obligate you to receive treatment from PF&C.

Understanding the Good Faith Estimate

• This is only an estimate. Actual costs may vary depending on your treatment needs, goals, and progress.
• You will receive this estimate before services begin or upon request.
• If you are charged $400 or more above this estimate, you have the right to initiate a dispute resolution process through the U.S. Department of Health and Human Services (HHS).
• You are encouraged to speak with your provider regularly about treatment frequency, progress, and any anticipated changes to your care plan.
  

Coverage Report Process (For Clients Using Insurance)

If you are using health insurance, PF&C offers a Coverage Report to help clarify your benefits and any out-of-pocket costs, such as copay, coinsurance, or deductible amounts.

To Begin:

• Upload a clear image of the front and back of your insurance card using the secure SimplePractice client portal.
  

How We Verify:

• PF&C uses Availity, a HIPAA-compliant online portal, to verify mental health benefits electronically.
• We attempt to confirm:

• Active coverage status
• Copayment or coinsurance
• Deductible remaining
• Prior authorization requirements
• In-network vs. out-of-network status
  

If Electronic Verification Fails:

• If coverage cannot be located electronically, PF&C may contact your insurance provider by phone.
• These calls are scheduled during administrative availability, outside of clinical appointments, and may take longer to complete.
  

Please Note:

• The information received in the coverage report is not a guarantee of payment.
• Final determination of benefits and payment is made by your insurance company.
• You are responsible for any fees not covered by your insurer.
  

You are encouraged to contact your insurance company directly for confirmation of benefits.

Estimated Cost of Services

Below is a list of common service codes and associated estimated fees. You and your provider will collaboratively determine which services are clinically appropriate.

Note: Frequency and duration of treatment will vary and be reviewed periodically based on clinical need and your treatment goals.

Your Options and Protections

• No Surprise Billing: You are protected from balance billing for emergency services or certain non-emergency services received from out-of-network providers at in-network facilities.
• You may dispute charges: If your final bill exceeds this estimate by $400 or more, you can initiate a dispute through the HHS website at www.cms.gov/nosurprises or by calling 1-800-985-3059.
• You may decline to sign this form: However, PF&C may not be able to provide services unless the estimate is acknowledged.
  

For more information on your rights under the No Surprises Act, visit: CMS Patient Protections Disclosure Notice Model Disclosure Notice Regarding Patient Protections Against Surprise Billing | CMS

Acknowledgment of Receipt and Understanding

By signing below, I acknowledge the following:

• I have received and understand this Good Faith Estimate of expected charges.
• I understand that the actual cost of services may vary based on my care needs.
• I understand that PF&C will attempt to verify my insurance coverage using the Availity portal and, if necessary, via scheduled phone calls.
• I understand that I am financially responsible for any charges not covered by my insurance plan.
• I understand that if my billed charges exceed this estimate by $400 or more, I have the right to dispute the charges.
• I understand that I may choose not to sign this estimate and seek care elsewhere.
  

CLIENT NAME (PLEASE PRINT): ______________________________

CLIENT SIGNATURE (ADULTS ONLY): ___________________________ DATE: ___________

IF CLIENT IS A MINOR, 17 YEARS OR YOUNGER, PLEASE CONTINUE BELOW:

PARENT/GUARDIAN’S NAME (PLEASE PRINT): ________________________________

PARENT/GUARDIAN’S SIGNATURE: _____________________________ DATE: __________