Good Faith Estimate Notice

Your right to receive a Good Faith Estimate of expected charges

Under the federal No Surprises Act, you have the right to receive a Good Faith Estimate of what your care is expected to cost if you don't have health insurance, or if you have insurance but choose not to use it (self-pay). This applies to clients who pay me directly, including clients who request a superbill to submit to their insurance for out-of-network reimbursement.

You can ask for a Good Faith Estimate at any time, including before you schedule. If you schedule a session at least 3 business days in advance, I will give you one in writing, on paper or electronically, whichever you prefer. Asking me about the cost of care counts as a request.

A Good Faith Estimate shows the charges I expect for my services. It is an estimate, not a bill, and your final charges may differ.

If the bill you receive is at least $400 more than your Good Faith Estimate, you have the right to start a dispute (called patient-provider dispute resolution). You must start it within 120 calendar days of the date of the bill. Keep a copy of your estimate.

To request an estimate or ask a question, contact me at info@rouamft.com or (631) 450-2295.

To learn more about your rights, visit cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.