YOUR RIGHT TO A GOOD FAITH ESTIMATE

(Under the No Surprises Act / 45 CFR § 149.610)

You have the right to receive a "Good Faith Estimate" explaining how much your medical and mental health care will cost.

Under the law, health care providers must give patients who do not have insurance or who are not using insurance an estimate of the expected bill for medical items and services, including psychotherapy and psychological assessments.

Your Rights Under the No Surprises Act:

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like individual therapy, psychological testing, and administrative fees.

  • Delivery Timelines: 

    • If you schedule a service at least 3 business days in advance, your written Good Faith Estimate will be provided within 1 business day of scheduling. 

    • If you schedule a service at least 10 business days in advance, your written Good Faith Estimate will be provided within 3 business days of scheduling. 

    • You can also request a Good Faith Estimate at any time before scheduling a service. In this case, it will be provided within 3 business days of your request. 

  • Disputing a Bill: If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill through the federal patient-provider dispute resolution process. You must initiate the dispute process within 120 calendar days of the date on the original bill 

  • Record Keeping: Make sure to save a copy or picture of your Good Faith Estimate for your records. 

Note: A Good Faith Estimate is an estimate of expected costs based on information known at the time it was created. It does not commit or obligate you to obtain any services from Aspen Grove Psychological Services, PLLC, nor does it guarantee the exact duration of treatment, as clinical needs may change over time. 

Contact Information for Inquiries or Disputes:

If you have questions or need more information about your Good Faith Estimate or your right to receive one at Aspen Grove Psychological Services, PLLC, please contact:

  • Practice Name: Aspen Grove Psychological Services, PLLC

  • Owners: Lauren Simicich, PsyD & Samuel Stork, PsyD

  • Email: info@aspengrove-psych.com

Federal Dispute Info: For more information about your rights under federal law or to initiate a dispute, visit www.cms.gov/nosurprises or call 1-800-985-3059.