Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your medical/behavioral healthcare will cost.
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes (under the law/when applicable) related costs like medical tests, prescription drugs, equipment, and hospital fees.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
Make sure your health care provider gives you a Good Faith Estimate within the following timeframes:
- If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling;
- If the service is scheduled at least 10 business days before the appointment date, no later than three business days after the date of scheduling; or
- If the uninsured or self-pay patient requests a good faith estimate (without scheduling the service), no later than three business days after the date of the request. A new good faith estimate must be provided, within the specified timeframes if the patient reschedules the requested item or service.
The No Surprises Act has a universal waiver form required — which Imara Counseling has adapted into an identical online form. You may view the PDF of the universal CMS waiver here.
This is the public disclosure of the “Good Faith Estimate”
Note: A Good Faith Estimate is for your awareness only. It does NOT involve you needing to make any type of commitment or to follow through on receiving mental health services here at Imara Counseling.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
If you have questions or concerns, please feel free to contact us at 409-210-7210.
Example of our Good Faith Estimate
Good Faith Estimate Explanation