Your Right to a Good Faith Estimate

Under the No Surprises Act, health care providers are required to provide clients who are uninsured or choosing not to use insurance with a Good Faith Estimate of expected charges for services.

The Intimacy Room Marriage and Family Therapy PLLC is a private pay practice. You have the right to receive a written Good Faith Estimate outlining the anticipated cost of therapy services before treatment begins.

What Is a Good Faith Estimate?

A Good Faith Estimate provides an estimate of the total expected cost of therapy based on the information available at the time it is created. It includes your session fee and the projected number of sessions discussed during your consultation.

This estimate is not a contract and does not require you to complete a specific number of sessions. Therapy is collaborative and the length of treatment may evolve depending on your needs.

Current Session Fees

Individual Therapy: $___ per 50-minute session
Couples Therapy: $___ per 50-minute session

Extended sessions or specialty services are billed at a prorated rate.

How Your Estimate Is Determined

Your Good Faith Estimate is based on:

• The type of service requested (individual or couples therapy)
• The anticipated frequency of sessions
• The expected duration of care discussed at the start of treatment

You will receive your personalized Good Faith Estimate in writing before your first session.

Changes to Your Estimate

If your treatment plan changes, an updated estimate will be provided.

Your Rights

If you are billed at least $400 more than your Good Faith Estimate, you have the right to dispute the charges through the U.S. Department of Health and Human Services.

For more information about your rights under the No Surprises Act, visit:

www.cms.gov/nosurprises

If you have any questions regarding fees or your estimate, please contact:

The Intimacy Room Marriage and Family Therapy PLLC
Jess@theintimacyroom.com
NY Telehealth | Private Pay