No Surprises Act: Good Faith Estimate Template

**Please note this is not a contract and does not create an obligation to receive these services

1. Patient name: xyz
2. Description of the primary service: Individual psychotherapy sessions
3. Applicable diagnosis codes, expected service (CPT) codes, and expected charges.
      Diagnosis (ICD code): to be determined
      CPT Code: 90834 (45 minutes of individual psychotherapy)
      Fee Per Session: will be provided with initial contact via email or phone.
4. Name of provider: William C. Sanderson, PhD -- NY Psychologist #10084, Tax ID# 30-0285755, NPI #1083765432
5. List of items or services that you anticipate will require separate scheduling: none
6. You are signing below to acknowledge the italicized provider statement that follows.  Psychotherapy is an ongoing process and thus it is impossible to determine the exact amount of service you will use during any calendar year. The number of sessions used will be based on your needs and preferences and can range from as few as 1 session and as many as 52 (although unlikely, it is possible to use more than 1 session/week which would be greater than 52 sessions). You have the ability to adjust the service provided on an ongoing basis as needed (increase, decrease, terminate, resume) which will affect the total number of sessions utilized.  The ultimate total fee (good faith estimate) for treatment services during 2022 will be the number of sessions you utilize multiplied by the agreed upon session fee.
8. If at any point you receive an unexpected charge (ie, surprise bill) from me please let me know.

 Do not hesitate to contact me if you have any questions about this form

Disclaimer

This 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. The Good Faith Estimate does not include any unknown 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 are billed for more than this Good Faith Estimate, you have the right to 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 update the bill 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) of the date on 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. To learn more and get a form to start the 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. You may also have rights under the New York Emergency Medical Services and Surprise Bill Act. For more information call 800-342-3736 or surprisemedicalbills@dgs.ny.gov. You may also file a complaint at https://www.dfs.ny.gov/IDR.