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).
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.
For full details on your dispute rights, visit 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).
