Health Insurance Claim Form
This form is best viewed on a desktop or laptop
Good Faith Estimate
You have the right to ask and receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services including psychotherapy. You can ask your health care provider, and any other provider you chose, for a Good Faith Estimate before you schedule a service. 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 a picture of your Good Faith Estimate.
For any questions or for more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (800) 985-3059