Good Fait Estimate

Beginning January 1, 2022, mental health professionals and other healthcare providers are required to provide an estimate of costs to clients who are paying for services who do not have insurance or who are not using their insurance. 

The Child and Family Connection will provide you with a written estimate of what your costs could be if you decide to come to therapy. While it is not possible for your therapist to know, in advance, how many therapy sessions may be necessary or appropriate, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of therapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. 

A client can expect to be billed at the time of each session. The rate of each session is as stated in the FAQs, and in the informed consent that is reviewed and signed at the onset of treatment. Clients are also welcome to request an updated Good Faith Estimate at any time. The Good Faith Estimate is not a contract and does not require the uninsured individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.

The Child and Family Connection does not accept any form of insurance and are not in-network providers. Your therapist is able to provide a monthly superbill if you wish to submit an out-of-network claim to your insurance. We cannot guarantee that your insurance will reimburse payment. You are strongly encouraged to check with your insurance provider to determine whether you will receive any reimbursement from your insurance company as well as what documents are needed to process claims.

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 more than $400 than your Good Faith Estimate, you have the right to 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. 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) 368-1019.

You may start a bill 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 the 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.

If you have any additional questions or concerns, please contact your therapist.