GOOD FAITH ESTIMATE NOTICE

You have the right to receive a Good Faith Estimate explaining the expected cost of your care.

Under federal law, healthcare providers must provide uninsured clients—and clients who choose not to use insurance—with an estimate of the expected charges for nonemergency healthcare services when those services are scheduled sufficiently in advance or when an estimate is requested.

The self-pay fee for a standard 55-minute psychotherapy session with Healing Bridge Psychotherapy, LLC is $150. The total expected cost of treatment will depend on the number and frequency of sessions. You may ask Christina for a written Good Faith Estimate before scheduling or at any time during treatment.

A Good Faith Estimate is not a contract and does not require you to receive services from Healing Bridge Psychotherapy. It is based on information reasonably known when the estimate is created and may not include services that could not reasonably have been anticipated.

If you receive a bill that is at least $400 more than the amount listed on your Good Faith Estimate, you may be eligible to dispute the bill through the federal patient-provider dispute-resolution process.

For questions or to request a written Good Faith Estimate, contact:

Christina Loftus, JD, LICSW, LCSW, ACC
Healing Bridge Psychotherapy, LLC
yourbestself@christinaloftus.com
952-737-0008

For additional information about your federal rights, visit cms.gov/nosurprises or call 1-800-985-3059.