Good Faith Estimate

You have the right to receive a Good Faith Estimate explaining how much your health care will cost.

Under the law, health care providers need to give patients who do not have certain types of health care coverage, or who are not using certain types of health care coverage, an estimate of their bill for health care items and services before those items or services are provided.

You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling those items or services.

If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.

A Good Faith Estimate is an estimate of expected charges. It is not a bill, guarantee, or contract for a fixed total cost. Actual charges may differ if services change, additional services become necessary, or relevant information was not reasonably known at the time the estimate was prepared. A Good Faith Estimate also may not include items or services scheduled separately, provided by another provider or facility, or not reasonably anticipated in advance.

If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.

Polaris Psychology generally operates as an out-of-network, private-pay practice for most services. Limited exceptions may apply in certain program-specific situations.

For questions about fees, estimates, or requesting an updated estimate, please contact Polaris Psychology directly.

For questions or more information about your right to a Good Faith Estimate, visit CMS.gov/medical-bill-rights, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

This page is provided as a general public notice and summary only. It does not replace any individualized written Good Faith Estimate or any rights or obligations established by federal law.