• The Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes (under the law/when applicable) related costs like medical tests, prescription drugs, equipment, and hospital fees.

• The Good Faith Estimate does not include any known or unexpected costs that may arise during treatment. YOu could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

  • You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. YOu can ask them to match the Good Faith Estimate, ask to negotiate the bill or ask if there is financial assistance available.​

  • You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process you must start the dispute process within 120 calendar days (about 4 months) from the date of the original bill.

  • There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this GOod Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

• Make sure your health care provider gives you a Good Faith Estimate within the following timeframes:

  • If the service is scheduled at least 3 business days before the appointment date - no later than one business day after the date of scheduling.​

  • If the service is scheduled at least 10 business days before the appointment date no later than 3 business days after the date you are scheduled; or

  • If the uninsured or self-pay patient requests a Good Faith Estimate without scheduling the service, no later than three business days after the date of the request. A new Good Faith Estimate must be provided within the specified timeframes if the patient reschedules the requested time or service.

• The NO Surprises Act has a universal waiver form required - which Butterfly Effect Counseling & Consultation Center has adapted into an identical online form. You may view the PDF of the waiver here.

• This is the public disclosure of the "Good Faith Estimate."

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NOTE: A Good Faith Estimate is for your awareness only. It does not require you to make any type of commitment and does not translate to an agreement for services with our office.  

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To learn more and get a form to start the appeal process, go to www.cms.gov/nosurprises or call 800-985-3059. FOr questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. 

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

If you have any questions or concerns please contact our office.