Right to Receive a Good Faith Estimate of Expected Charges (Under the No Surprises Act)

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost. Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

• You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.

• If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill. • Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

Chris M Johnston, LCSW- GOOD FAITH ESTIMATE

The base self-pay fee for a 50-minute session is $120. Occasionally, there is a discount such as a lower self-pay fee for the first session, etc. Whatever fees/discounts are current is posted on the “Paying for Therapy” page. If you are using your health insurance or a third party reimbursement of any kind, then the fees are set in accordance to the third party’s agreement with all stakeholders (You, the 3rd party organization, and provider). There is a 24-Hour cancellation or No-show fee policy that applies to clients who have signed and submitted the “Chris M Johnston, LCSW” intake forms prior to beginning therapy (normally at the start of the first session). Intake forms are sent to each client prior to their first scheduled session. The cancellation/no-show fees are equal to the fee revenue lost by the missed appointment (not based on a partial-fee responsibility such as a copay). Sometimes self-pay clients need to arrange a lower on-going fee through a “sliding scale” estimate. The lowest self-pay fee considered is $75 for a 50-minute session. It is recommended that a verbal discussion occur between client/Chris M Johnston, LCSW to fully agree on a lower self-pay fee. The Good Faith Estimate is agreed upon during the scheduling process and is accompanied with the intake forms sent to each new client prior to their first session.

PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.