Licensed ProvidersTelepsychiatry Available Serving Texas, Kansas & Minnesota
Good Faith Estimate
You have the right to receive an estimate of costs for your medical care. Federal law requires healthcare providers to provide this transparency to uninsured and self-pay patients.
Your Rights Under the No Surprises Act
Federal protections for uninsured and self-pay patients
Your Right to an Estimate
Under federal law, healthcare providers must provide uninsured or self-pay patients an estimate of charges for non-emergency medical items and services. This is known as a Good Faith Estimate.
What Is Covered
The estimate includes anticipated costs for the visit.
Applies to All Patients
Even if you have health insurance, you may request a Good Faith Estimate for scheduled services. This estimate provides transparency into your financial responsibility.
How to Request an Estimate
Steps to receive your Good Faith Estimate
Submit a Written Request
Ask any provider you see for an estimate of fees before receiving care or services. Your request must be submitted in writing.
Submit at Least One Business Day in Advance
Make sure to request your Good Faith Estimate at least one business day before any scheduled medical procedure or treatment.
Review Your Estimate
The Good Faith Estimate gives you transparency into your financial responsibility for your healthcare. Review it carefully and ask questions about any charges you do not understand.
Please note: You can ask any provider you see for an estimate of fees before receiving care or services, not just Pleasant Place Psychiatry.
Dispute Resolution
Your rights if billed more than the estimate
You Can Initiate the Patient-Provider Dispute Resolution Process
If your final bill exceeds the Good Faith Estimate by $400 or more, you have the right to initiate the federal patient-provider dispute resolution process to determine an appropriate payment amount.
Submit Within 120 Calendar Days
The dispute must be submitted within 120 calendar days of the date you were first billed for the service. A designated entity will review your case and determine an appropriate payment amount.
Important: The patient-provider dispute resolution process is a federal protection. If you believe your final bill is significantly higher than the Good Faith Estimate you received, contact us or visit CMS.gov/nosurprises for more information on how to initiate the process.
Questions About Our Policies?
We are here to help you understand our policies and how they support your care. Reach out anytime.