Good Faith Estimate (No Surprises Act)

Good Faith Estimate Policy (No Surprises Act)

BLACK SWAN COUNSELING SERVICES, LLC

YOUR RIGHT TO A GOOD FAITH ESTIMATE

Under the No Surprises Act (Public Law 116-260), health care providers are required to give patients who do not have insurance, or who are not using insurance, an estimate of the bill for medical items and services.

1. Overview of Your Rights

• You have the right to receive a Good Faith Estimate (GFE) for the total expected cost of any non-emergency items or services, including psychotherapy sessions, intakes, and assessments, provided by Black Swan Counseling Services, LLC.

• The GFE must be provided to you in writing at least 1 business day before your scheduled medical service or item. You can also ask your provider, and any other provider you choose, for a GFE before you schedule an item or service.

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

2. Practice Framework & Disclaimer

The Good Faith Estimate is only an estimate of items or services reasonably expected at the time of scheduling. It is based on the information known at the time the estimate is created. It does not include unexpected costs that may arise during the course of treatment due to unforeseen clinical developments or changes in your treatment plan.

If you request a change in session frequency or require additional clinical documentation (such as court reports or specialized assessments), a revised Good Faith Estimate will be provided to you.

3. Dispute Process

Initiating a dispute will not affect the quality or availability of the mental health care you receive at our practice. For questions or more information about your right to a Good Faith Estimate, or to learn how to dispute a bill, visit www.cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.