Strong Hope Counseling Center

GOOD FAITH ESTIMATE STATEMENT

NOTE: This is boiler plate, and should be reviewed to be sure it correctly matches your business practices

You have the right to receive a Good Faith Estimate of the expected cost of services.

Under the law, health care providers are required to give clients who do not have insurance or who are not using insurance an estimate of the expected charges for mental health services.

WHAT IS A GOOD FAITH ESTIMATE

A Good Faith Estimate shows the expected costs of services based on the information known at the time the estimate is provided. The estimate is not a contract and actual charges may differ depending on your treatment needs and length of care.

WHAT YOU CAN EXPECT

If you are uninsured or self pay, you may request a Good Faith Estimate before scheduling services or at any time during your care.

If you schedule services at least three business days in advance, you can request a Good Faith Estimate at least one business day before your appointment.

If you schedule services at least ten business days in advance, you can request a Good Faith Estimate at least three business days before your appointment.

DISPUTES

If you receive a bill that is at least four hundred dollars more than your Good Faith Estimate, you may have the right to dispute the bill.

More information about your rights is available at www.cms.gov/nosurprises or by calling 1 800 985 3059.

QUESTIONS OR REQUESTS

To request a Good Faith Estimate or to ask questions about fees and billing, please contact:

Strong Hope Counseling Center
operations@stronghopecounseling.com
(970) 414-0016
Fort Collins, CO