Your Rights Under the No Surprises Act

Under federal law (Section 2799B-6 of the Public Health Service Act), you have the right to receive a Good Faith Estimate (GFE) of the expected costs for your non-emergency mental health services.

This law is designed to prevent “surprise billing” for individuals who are:

• Uninsured

• Not using insurance (self-pay)

• Using out-of-network benefits and paying privately

• Receiving services outside of insurance or without submitting claims

As a provider who offers therapy to self-pay clients, I comply fully with this law.

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What is a Good Faith Estimate?

A Good Faith Estimate outlines the anticipated cost of therapy services over a defined period of time.

Your GFE will include:

• The type of service you’re receiving

• The frequency of sessions expected

• The estimated total cost of services

• Any additional fees (if applicable)

• Notice of your dispute rights

This estimate is not a bill.
Your actual costs may change depending on your needs, progress, preferences, and treatment planning.

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When Will You Receive a Good Faith Estimate?

You will receive a Good Faith Estimate:

• Before your initial appointment

• When requested

• Any time your fees or service plan changes

If your treatment plan changes significantly, I will provide an updated GFE.

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What is Included in the Estimate?

Your GFE may include:

• Individual therapy sessions

• Extended sessions

• EMDR sessions

• Administrative fees (if applicable)

• Any additional agreed-upon services

You will never be billed for anything not explicitly disclosed or agreed upon in writing.

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Your Right to Dispute a Resolution

If you receive a bill that is substantially higher than your Good Faith Estimate (defined as $400 or more above the estimate), you have the right to dispute the charge.

You may:

• Ask me to update the bill

• Negotiate the bill

• Request the bill be reviewed through the formal dispute resolution process established by the U.S. Department of Health and Human Services (HHS)

To learn more or start a dispute, visit:
https://www.cms.gov/nosurprises

If you choose to dispute a bill, you must do so within 120 days of the invoice date.

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What You Should Know

• A Good Faith Estimate is provided before services begin, but your actual treatment frequency and duration may vary depending on clinical need and your personal goals.

• The No Surprises Act does not apply to clients using in-network insurance through platforms such as Headway or Rula.

• You can request a Good Faith Estimate for any future services at any time.

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Estimated Fee Structure

A detailed estimate will be provided based on your individualized treatment plan.

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How to Request a Good Faith Estimate

You may request a GFE at any time by contacting me:

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info@tylerdawnee.com

tylerdawnee.com

California, USA

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Disclaimer Required by Federal Law

“You have the right to receive a Good Faith Estimate explaining how much your medical care will cost.
Under the law, healthcare providers must give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.

Make sure your provider gives you a Good Faith Estimate in writing at least 1 business day before your service.

You can also ask your provider for a Good Faith Estimate before you schedule a service.

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

For more information about your rights:
https://www.cms.gov/nosurprises