Good Faith Estimate (GFE)

Your Right to Receive a Good Faith Estimate

Under federal law, health care providers must give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including mental health services.

A Good Faith Estimate shows the expected charges for items and services you may receive from KwikPsych. It is not a bill and not a contract.

Who This Applies To

You have the right to receive a Good Faith Estimate if you:

• Do not have health insurance
• Have insurance but choose to pay out of pocket (self-pay) at KwikPsych
• Request cost information before scheduling a service

When You Can Get an Estimate

Uninsured or self-pay patients can request a Good Faith Estimate at any time before scheduling or receiving services.

For scheduled services:

• If the service is scheduled at least 3 business days in advance, you will receive the estimate within 1 business day of scheduling.
• If the service is scheduled at least 10 business days in advance, you will receive the estimate within 3 business days of scheduling.
• If you request an estimate before scheduling, it will be delivered within 3 business days.

Estimates may be delivered by mail, secure email/portal, or in person.

What Will Be in Your Estimate

Your Good Faith Estimate will include:

• Your name and contact information
• KwikPsych’s identification and contact information
• Descriptions of the services reasonably anticipated
• Itemized expected services with individual charges
• Total estimated cost of care

Because mental health care is individualized and may evolve over time, the estimate may include a range or number of visits that reflects your anticipated treatment needs.

Limits of a Good Faith Estimate

The estimate is based on information available at the time it is created. It does not include services that are separately scheduled or changes in care that could not be foreseen.

Actual treatment, visit frequency, and total expenses may differ based on your individual needs and preferences. KwikPsych will discuss your goals and update your estimate when your care plan changes.

If Your Bill Is Higher Than the Estimate

If your final bill exceeds the Good Faith Estimate by $400 or more, you may be eligible to dispute the charges. You should:

• Contact KwikPsych to review the billing and documentation
• Request corrections to any erroneous bills or estimates
• Ask about payment plans or hardship accommodations

Federal Dispute Resolution

The U.S. Department of Health and Human Services (HHS) offers a patient-provider dispute process:

• You must initiate the dispute within 120 calendar days of the original bill date
• There is currently a $25 administrative fee (subject to change by HHS)

Additional resources:

• Website: www.cms.gov/nosurprises/consumers
• Email: FederalPPDRQuestions@cms.hhs.gov
• Phone: 1-800-985-3059

Please keep a copy of your Good Faith Estimate for your records. It may be helpful if you receive unexpected bills or need to file a dispute.