Good Faith Estimate of Charges

Under the new law, the “No Surprise Act 2022” health care providers need to give clients who do not have insurance or who are not using insurance, an estimate of the costs for medical items and counseling services at Sycamore Counseling Services, LLC.

• You have the right to receive a Good Faith Estimate for the expected cost of
  any non-emergency items or services. This includes related costs like counseling services or testing.

• We will make sure you receive a Good Faith Estimate in writing or electronically before your medical service or item.

• Make sure you make a copy or picture of your Good Faith Estimate.

• There may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate.

• That the information provided in the Good Faith Estimate is only an estimate and that actual items, services, or charges may differ from the Good Faith Estimate.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. The initiation of a patient-provider dispute resolution process will not adversely affect the quality of your care.

• The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) client to obtain the items or services from any of the providers or facilities identified in the good faith estimate.

For questions, more information, or to file a complaint about your rights go to: www.cms.gov/nosurprises.