Your Right to a Good Faith Estimate
Under the No Surprises Act (2022), health‑care providers must give uninsured and self‑pay clients a written estimate of reasonably expected charges before services are delivered. This is called a Good Faith Estimate (GFE).
Healthcare providers and healthcare facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, to receive a “Good Faith Estimate” of expected charges.
You have the right to :
- Receive the GFE in writing at least 3 business days before your first appointment (or sooner upon request);
- Ask for an updated GFE at any time if your treatment plan, session frequency, or fees change; and
- Dispute any bill that is $400 or more above the total listed on your most recent GFE.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, healthcare 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. You can also ask your healthcare 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 or call 1‑800‑985‑3059.
Why You Are Seeing This Notice
Polaris Psychology is an out‑of‑network, private‑pay practice. We do not bill or accept insurance. Because your health plan may not reimburse you, you are responsible for the entire fee at the time of service.
Potential Future Changes That Trigger an Updated GFE
- Moving from monthly to weekly sessions (or vice‑versa)
- Adding psychological testing or another specialized service
- Updated practice fees or policies
- 12 months
You may request a new GFE anytime by emailing your clinician.
Diagnosis & Service Codes
A mental‑health diagnosis (ICD‑10) may not be determined at your first visit—or at all—if your concerns do not meet diagnostic criteria. Your fee is the same whether a diagnosis is assigned. If a diagnosis or additional CPT codes become relevant later, we will update your estimate upon request.
Questions, Updates, or Disputes
If your final bill is $400+ higher than your most recent GFE, contact us first—we are happy to review and correct errors. If we cannot resolve the difference, you may start the federal dispute process within 120 days of the bill date (see CMS.gov/nosurprises).