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No Surprises Act - Good Faith Estimates

Beginning January 1, 2022, health care providers and facilities must provide a good-faith estimate of expected charges to uninsured consumers, or to insured consumers if they don’t plan to have their health plan help cover the costs (self-paying individuals). Since Feelings Forward Wellness, LLC does not accept insurance, this would apply to clients under FFW's care. The good-faith estimate must be provided after a patient has scheduled an item or service, or upon their request. It should include expected charges for the primary item or service they’re getting, and any other items or services that are provided as part of the same scheduled experience. Please keep a copy of your Good Faith Estimate in a safe place.

Surprise billing occurs when clients receive care from out-of-network providers without their knowledge. Surprise billing therefore results in higher costs for medical services that would have been cheaper if rendered by providers inside their health plan’s network. This can happen when someone involved in the client’s care is not in-network. The rule is intended to cut down on surprise costs, and also to ban out-of-network charges without notice in advance (providing clients plain-language consumer notice). The Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. The estimated costs are valid for 12 months from the date of the Good Faith Estimate. If there is a change in fee, a new GFE document will be provided.

Consumer Notice
I will provide a Good Faith Estimate with the verbally agreed-on fee that was set at consultation per request. This will be sent to your email with the rest of your intake forms when an initial appointment is scheduled. If you request, I will also provide this notice to you in paper or electronic format, as you prefer or you may receive a copy. You are never required to give up your protection from surprise billing. You also are not required to get out-of-network care. You can choose a provider or facility in your plan’s network.

If you are billed for more than the Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to or call HHS at (800) 368-1019.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit or call (800) 368-1019.

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