Good Faith Estimate — No Surprises Act Notice
No Surprises Act — Good Faith Estimate Notice
29 CFR § 149.610 / 45 CFR § 149.610 — Federal Requirement (effective January 1, 2022)
YOUR RIGHT TO A GOOD FAITH ESTIMATE
Under the federal No Surprises Act (effective January 1, 2022), health care providers — including psychologists in private practice — are required to provide clients who are uninsured or opting not to use insurance with a Good Faith Estimate of expected charges before delivering psychological services.
Who Receives a Good Faith Estimate?
You are entitled to a Good Faith Estimate if you are uninsured OR if you have insurance but choose to self-pay for services with this provider.
What It Includes
– Expected charges for psychological services (intake, individual therapy, testing, etc.)
– Applicable CPT codes and diagnosis codes (if known)
– Estimated number of sessions over a 12-month period
– Practice name, contact information, and National Provider Identifier (NPI)
Your Dispute Rights
If Your Bill Is $400+ Above the Estimate
You have the right to dispute a bill that exceeds your Good Faith Estimate by $400 or more.
To initiate a dispute:
www.cms.gov/nosurprises | 1-800-985-3059
Deadline to dispute: Within 120 days of receiving the bill
Keep a copy of your Good Faith Estimate — you will need it to support your dispute.
To request a Good Faith Estimate or for any billing questions, please contact:
Billing Department
Search for Meaning Therapy
Phone: 858-758-0587
