Good Faith Estimate

We will provide you with a "Good Faith Estimate" of what the charges could be for psychotherapy services provided to you. This notification is not a contract, but simply an estimate that helps clients become more aware of and informed about the potential costs of therapy, so that there are no surprises. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this process provides an estimate of the cost of services provided to you through the end of the calendar year. In our group, our estimates are only through December 31 of each year, for a maximum period of 12 months. Your total cost of services through December 31 will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. If you continue working with MCAFT after the new year begins, we will send you a new Good Faith Estimate for the next 12-month period. An estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified. The reason is simply to notify you that you have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). For questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call 1-800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services provided to you. A Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time. You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in a Good Faith Estimate.