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GOOD FAITH ESTIMATE NOTICE
  1. ADMINISTRATIVE CONTEXT STATEMENT
This page provides factual information regarding Good Faith Estimate rights for uninsured or self-pay individuals under federal No Surprises Act protections. It is provided to support practice transparency, assist in administrative verification, and clarify cost-estimate rights connected to scheduled online psychotherapy services.
The active clinical authority for all psychotherapeutic services described on this website is the Pennsylvania Licensed Professional Counselor (LPC) credential.
The Ph.D. reflects academic and research background. It does not indicate psychologist licensure and does not mean this practice provides psychological testing, psychological evaluations, school psychology services, forensic evaluations, disability evaluations, ADHD testing, autism testing, or educational assessment services.
  1. PURPOSE OF THIS NOTICE
Under federal No Surprises Act protections, uninsured or self-pay individuals generally have the right to receive a Good Faith Estimate of expected charges for scheduled health care items or services.
A Good Faith Estimate is not a bill. It is an estimate of expected charges based on the information known at the time the estimate is prepared.
This notice applies to Good Faith Estimate information for uninsured or self-pay individuals receiving scheduled individual online outpatient psychotherapy services through this practice.
  1. WHO MAY RECEIVE A GOOD FAITH ESTIMATE
A Good Faith Estimate may apply when an individual:
  1. Does not have health insurance
  2. Has health insurance but chooses not to use it for the service
  3. Schedules a health care item or service at least 3 business days in advance
  4. Requests a Good Faith Estimate
The Good Faith Estimate requirement applies to uninsured or self-pay individuals. It does not guarantee that insurance will cover services, reimburse services, approve claims, or assign a specific client responsibility.
  1. WHAT A GOOD FAITH ESTIMATE MAY INCLUDE
A Good Faith Estimate generally includes expected charges for scheduled health care items or services.
For this practice, the estimate may include expected charges related to scheduled individual online outpatient psychotherapy services.
A Good Faith Estimate is based on information available at the time it is prepared. Actual charges may differ if the service schedule changes, if additional services are requested, if the course of care changes, or if other relevant information changes.
  1. TIMING OF GOOD FAITH ESTIMATES
A Good Faith Estimate is generally provided when an uninsured or self-pay individual schedules care at least 3 business days in advance or requests an estimate.
If services are scheduled far enough in advance, timing requirements may vary based on the date of scheduling and applicable federal requirements.
A Good Faith Estimate is not required during emergency care. This practice does not provide emergency or crisis services.
  1. DISPUTE RIGHTS
An uninsured or self-pay individual may have the right to use the federal patient-provider dispute resolution process if the final bill from a provider is at least $400 more than the Good Faith Estimate from that provider.
The dispute process is administered through federal No Surprises Act procedures. The practice does not determine whether a dispute will be accepted, how an independent dispute decision will be resolved, or what final payment amount may be determined through that process.
  1. PRESERVING A GOOD FAITH ESTIMATE
An individual who receives a Good Faith Estimate should keep a copy of the estimate.
The estimate may be needed if the individual later seeks to use the patient-provider dispute resolution process.
  1. INSURANCE AND PAYMENT SEPARATION
This page does not replace the Insurance & Billing Guide.
The Insurance & Billing Guide explains insurance verification questions, NPI information, common insurance terms, and payment workflow.
This Good Faith Estimate Notice addresses federal cost-estimate rights for uninsured or self-pay individuals.
  1. NO COVERAGE OR COST GUARANTEE
This page does not guarantee:
  1. Insurance coverage
  2. Claim approval
  3. Reimbursement
  4. Network status
  5. Final client cost
  6. A specific billing outcome
  7. Acceptance of any dispute
  8. The result of any dispute process
Insurance benefits, coverage, allowed amounts, deductibles, copays, coinsurance, authorization requirements, and client responsibility are determined by the client’s insurance plan when insurance is used.
  1. SCOPE AND SERVICE LIMITATIONS
This Good Faith Estimate Notice applies strictly to scheduled individual online outpatient psychotherapy provided to adults physically located in Pennsylvania at the time of service under the authority of the Pennsylvania Licensed Professional Counselor (LPC) license.
This practice does not provide:
  1. In-person therapy
  2. Walk-in appointments
  3. Hybrid in-person and telehealth care
  4. Therapy for children or adolescents under age 18
  5. Couples therapy
  6. Family therapy
  7. Group therapy
  8. Psychological testing
  9. Psychological evaluations
  10. Psychoeducational evaluations
  11. ADHD assessments
  12. Autism assessments
  13. School psychology services
  14. Educational evaluations
  15. Forensic, custody, disability, or court-related evaluations or reports
  16. Medication management
  17. Psychiatric prescribing
  18. Crisis response or emergency intervention services
  19. Coaching or consulting services
  20. Psychotherapy services for clients located outside Pennsylvania at the time of service
  21. EXTERNAL INFORMATION LINKS
General CMS information about Good Faith Estimates for people who do not have insurance or are not using insurance is available here:
https://www.cms.gov/medical-bill-rights/know-your-rights/no-insurance
CMS information about disputing a bill that is at least $400 more than a Good Faith Estimate is available here:
https://www.cms.gov/medical-bill-rights/help/dispute-a-bill
CMS information about patient-provider dispute resolution is available here:
https://www.cms.gov/nosurprises/providers-payment-resolution-with-patients
  1. CLOSING ADMINISTRATIVE STATEMENT
This notice is provided for cost-transparency information under federal Good Faith Estimate and No Surprises Act protections. Current services remain limited to scheduled individual online outpatient psychotherapy for adults physically located in Pennsylvania, provided under the Pennsylvania Licensed Professional Counselor credential.