Good Faith Estimate Notice

Last updated: September 15,2026

Your Right to a Good Faith Estimate

Under the No Surprises Act, health care providers and facilities are required to give patients who are uninsured or who are not using insurance an estimate of expected charges for services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency services, including psychotherapy and related items, if you are: Uninsured, or Insured but not planning to submit a claim to your insurance for the services (self-pay)

What a Good Faith Estimate Includes

Your Good Faith Estimate will show the expected charges for the services reasonably expected to be provided, including: The clinician's name and NPI number A description of the primary service (e.g., individual psychotherapy) The expected frequency and duration of treatment, if known Diagnostic codes and service codes, where applicable The expected cost per session and estimated total cost, based on the anticipated course of treatment Because ongoing psychotherapy needs can change over time, your estimate reflects expected costs based on the information available at the time it is provided, and may be updated if your treatment plan changes.

When You Will Receive It

If you schedule an appointment for services at least 3 business days in advance, you will receive your Good Faith Estimate no later than 1 business day after scheduling. If you schedule at least 10 business days in advance, you will receive it no later than 3 business days after scheduling. You may also request a Good Faith Estimate at any time before scheduling an appointment.

How to Request a Good Faith Estimate

To request a Good Faith Estimate, contact us at [631.514.5433] or [info@ot-counseling.com]. There is no charge for requesting or receiving a Good Faith Estimate.

Your Right to Dispute

If you receive a bill that is at least $400 more than your Good Faith Estimate for the same provider or facility, you have the right to dispute the bill. You may start a dispute process through the U.S. Department of Health and Human Services (HHS) if you believe you were charged more than the Good Faith Estimate. Disputes must generally be initiated within 120 calendar days of the date on the original bill.

For more information about your right to a Good Faith Estimate and the patient-provider dispute resolution process, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Keep a Copy

Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises, or contact us directly at (631) 514-5433 or info@ot-counseling.com