The following forms provide specific details regarding your rights as a client and practice policies. Upon scheduling your first session, you will be prompted to read and sign all appropriate forms. Our Practice Policies and Good Faith Estimate can be viewed below.

No Surprises Act Information

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• 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 medical tests, prescription drugs, equipment and hospital fees.
• You have the right to receive a Good Faith Estimate in writing at least one business day before your medical service or item. Generally speaking, you can also ask your healthcare provider for a Good Faith Estimate before you schedule an item or service. Unsung Psychotherapy’s general Good Faith Estimate is provided below.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

Get More Information

For questions or more information about your right to a Good Faith Estimate, please visit cms.gov/nosurprises or call 1-800-MEDICARE (1-800-633-4227).