Effective Date: May 17, 2026
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 don’t 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 such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- 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.
- 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.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email [email protected], or call 1-800-985-3059.
What this means at Polaris Psychology
Polaris Psychology, PLLC (“Polaris Psychology”) is out-of-network with all health insurance plans and operates on a private-pay basis. Polaris Psychology provides an individualized written Good Faith Estimate to each uninsured or self-pay client at intake through its electronic health record system. That document describes the expected charges for the services being scheduled, the client’s rights, and dispute options in more detail.
Some clients receive services under specialty program arrangements with different billing terms. Those clients receive program-specific intake documents that govern their billing, and the standard Good Faith Estimate process described above may not apply to those arrangements.
For questions about Polaris Psychology’s fees, an existing Good Faith Estimate, or to request an updated estimate, please contact:
Polaris Psychology, PLLC
- Email: [email protected]
- Phone: (800) 240-5716
- Mail: 52 Nashua Street, Suite 19, Milford, NH 03055-3717
- NPI: 1457923682
Accessible formats and language access
If you need this notice in a language other than English, or in an alternate accessible format, please contact Polaris Psychology using the information above. Polaris Psychology aims to provide notice information in formats and languages that allow meaningful access, consistent with applicable law and available resources.
Other terms
This page is provided as a general public notice and summary. It is not itself a Good Faith Estimate of expected charges. The information on this page does not:
- Create a contract, third-party beneficiary right, or any other legal entitlement
- Modify or supersede any individualized Good Faith Estimate provided by Polaris Psychology, any service-specific consent or intake document, or any other written agreement with Polaris Psychology
- Waive any defense, immunity, or limitation otherwise available to Polaris Psychology under applicable law
- Override any right or obligation established by federal or state law
In the event of any inconsistency between this page and an individualized written Good Faith Estimate, a service-specific consent or intake document, or applicable law, the individualized document or applicable law controls.
If any provision of this page is determined to be invalid or unenforceable, the remaining provisions remain in effect.
Polaris Psychology may update this page from time to time. The “Last Updated” date above indicates when this page was most recently revised.