Legal · No Surprises Act

Good Faith Estimate

You have the right to receive a written estimate of what your care will cost if you are uninsured or choose not to use insurance.

Effective: [DATE]Public Health Service Act § 2799B-6Self-pay & uninsured
Draft for legal review. The No Surprises Act requires specific disclosure language and a written estimate delivered within set timeframes. The framing below reflects those requirements, but the final wording and the practice's fee schedule must be confirmed by the practice's attorney or billing advisor before launch.
Section 01

Your right to a Good Faith Estimate

Under the No Surprises Act, you have the right to receive a Good Faith Estimate explaining how much your medical and mental health care will cost.

Health care providers are required to give patients who are uninsured, or who are not using insurance, an estimate of the expected charges for medical services, including psychotherapy services.

Section 02

Who this applies to

This applies if you do not have health insurance, or if you have insurance but choose not to use it for your care with us. If you are using insurance, your costs are instead governed by your plan's benefits, deductible and copay.

Section 03

When you will receive it

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency services, including psychotherapy and medical services. You can ask us for one before you schedule, and we will also provide one when you schedule care.

  • If you schedule at least three business days in advance, you will receive the estimate within one business day of scheduling
  • If you schedule at least ten business days in advance, you will receive it within three business days
  • If you simply ask for an estimate, you will receive it within three business days of your request
Section 04

What the estimate includes

Because ongoing therapy and medical care are open-ended, our estimate describes the expected charge per session or visit and the anticipated frequency and duration of care, so you can see the expected cost over a period of time.

Our current published rates: intake $195 self-pay / $225 with insurance; 50-minute session $140 self-pay / $185 with insurance; 15–30 minute session $75 self-pay / $150 with insurance. Discounts are available for self-pay clients based on income verification. Your written estimate will apply these rates to the anticipated frequency and duration of your care.
Section 05

If your bill is higher than your estimate

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Keep your estimateMake sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.
Section 06

How to request one

Contact our office and we will prepare a written Good Faith Estimate for you. Asking for an estimate does not commit you to scheduling care.

PracticeOmetz HealthAddress897 W Lee Highway, New Market, VA 22844Phone(540) 726-6777Emailinfo@ometzhealth.com