Notice of Right to Receive a Good Faith Estimate

Your Right to Receive an Estimate of Expected Health Care Costs

Under the federal No Surprises Act, you have the right to receive a Good Faith Estimate explaining how much your health care services are expected to cost if you do not have health insurance or choose not to use your insurance to pay for your care.

What is a Good Faith Estimate?

A Good Faith Estimate provides an estimate of the expected charges for health care services you receive from a provider. It is not a bill.

Your rights as a patient

• You have the right to request a Good Faith Estimate before scheduling services.
• If you are uninsured or choose not to use your insurance, you generally have the right to receive a written estimate when you schedule services at least 3 business days in advance or request an estimate.
• You may ask questions about the expected cost of your psychiatric evaluation, medication management, and other anticipated services.
• If you receive a bill from your provider that is at least $400 more than your Good Faith Estimate for that provider, you may be eligible to dispute the bill through the federal Patient-Provider Dispute Resolution process.

How to request a Good Faith Estimate

To request an estimate or ask questions about expected charges, please contact:

Practice: Her Mental Health

Provider: Saba Rastegar, DNP, PMHNP-BC, IBCLC

Phone: 703-970-7048

Email: info@hermentalhealth.org

We are committed to transparency and helping you make informed decisions about your mental health care.

For more information about your rights under the No Surprises Act, visit:

https://www.cms.gov/nosurprises

You may also contact the U.S. Department of Health and Human Services at 1-800-985-3059 for information about your rights.