No Surprise Act

No Surprises Act & Good Faith Estimate

Under the No Surprises Act, you have the right to receive a “Good Faith Estimate” (GFE) explaining the expected cost of your care.

Your Rights

You have the right to receive a Good Faith Estimate in writing for the total expected cost of non-emergency healthcare services, including psychotherapy services.

This estimate will include the expected charges for services provided by Heal and Restore PLLC.

You may request a Good Faith Estimate before scheduling services or at any time during treatment.

When You Will Receive a Good Faith Estimate

If you are uninsured or not using insurance, you will receive a Good Faith Estimate:

At least 1 business day before your scheduled service (if scheduled 3–9 days in advance)

Within 3 business days of scheduling (if scheduled 10+ days in advance)

If requested, estimates will be provided within 3 business days.

Important Information

The Good Faith Estimate is not a contract and does not obligate you to receive services.

Actual charges may differ based on the services provided and clinical needs.

If you receive a bill that is $400 or more above your Good Faith Estimate, you have the right to dispute the bill.

Questions or Disputes

For more information or to dispute a bill, visit:

www.cms.gov/nosurprises/consumers⁠�

or call: 1-800-985-3059

You have the right to receive a “Good Faith Estimate” explaining how much your medical 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 bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item.You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or 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 picture of your Good Faith Estimate.

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

Surprise Billing Protections (Federal Law)

Although most outpatient therapy services are not typically subject to hospital-based surprise billing, federal law provides protections in certain situations.

What is “Balance Billing”?

“Balance billing” occurs when a provider bills you for the difference between:

What your insurance pays, and

The provider’s full charge

This usually applies to out-of-network providers.

Your Protections

You are protected from balance billing in the following situations:

Emergency Services

You cannot be charged more than your in-network cost-sharing amount (copay, coinsurance, deductible).

This applies even if the provider is out-of-network.

Certain Facility-Based Services

If you receive care at an in-network hospital or facility, certain providers cannot balance bill you (e.g., anesthesia, radiology, lab services).

Your Rights

You are not required to waive your protections.

You may choose in-network providers whenever available.

Your insurance must:

Cover emergency services without prior authorization

Apply payments toward your deductible and out-of-pocket limits

If you believe you have been incorrectly billed, contact:

1-800-985-3059 or visit www.cms.gov/nosurprises/consumers⁠

Professional Services & Limitations

Benefits and Risks of Therapy

Therapy can provide meaningful benefits, including:

Reduced emotional distress

Improved relationships

Increased coping skills

However:

Outcomes cannot be guaranteed

Therapy may involve discussing difficult or uncomfortable topics

Emotional discomfort may occur during the process

Confidentiality & Its Limits

Your privacy is important. Information shared in therapy is confidential and will not be disclosed without your written consent, except in the following situations required by law:

Exceptions to Confidentiality

Risk of Harm to Self or Others

If you disclose intent to harm yourself or another person, the therapist is required to take protective actions, which may include notifying appropriate parties or authorities.

Abuse or Neglect

Suspected or disclosed abuse or neglect of:

Children

Elderly individuals

Disabled or vulnerable adults

must be reported to the appropriate authorities.

Court Orders & Legal Proceedings

Records may be disclosed if required by a valid court order or subpoena.

Prenatal Exposure to Substances (as required by state law)

Certain disclosures may require reporting.

Minors

Parents or legal guardians may have the right to access records of non-emancipated minors, subject to applicable laws.

Insurance & Third-Party Payers

If you use insurance, relevant information may be shared for billing and reimbursement purposes.