Good Faith Estimate of Expected Charges Disclosure

Under the No Surprises Act

As a client, you have the right to receive a Good Faith Estimate that outlines the expected cost of your therapy services. This is designed to help you understand and anticipate your financial responsibility—before you receive care.

While no therapist can predict exactly how many sessions you’ll need, your therapist will discuss your goals with you and offer a general estimate based on what is known at the start of your work together. Your actual total cost will depend on the number of sessions you attend and the scope of services provided.

Key Facts About Your Estimate
• It’s not a contract. You’re not obligated to receive any services.
• It’s not a treatment plan. You can agree—or disagree—with recommendations and end therapy at any time.
• It’s based on what’s known now. The estimate may change if your needs change.

If your final bill is $400 or more above what was listed in your estimate, you have the right to dispute the charge. You can:
• Ask your therapist to explain the charges
• Request a corrected bill
• Negotiate a new payment plan
• Or file a dispute through the U.S. Department of Health & Human Services

How to Start a Dispute (if needed)

If you choose to use the federal dispute resolution process, you must start it within 120 days of the date on your bill. There is a $25 filing fee. The dispute will be reviewed by an independent reviewer.

For more information or to start the process: • Visit: www.cms.gov/nosurprises/consumers • Email: FederalPPDRQuestions@cms.hhs.gov • Call: 1-800-985-3059

⸻

Keep a copy of your Good Faith Estimate for your records. You may need it later if you receive a bill that seems unexpectedly high.

⸻

Couples Therapy Inc | 125 Guest St, Boston Landing, MA 02135 | 844-926-8753 | NPI: 1366008617

⸻