Good Faith Estimate & No Surprises Act
Effective Date:* [Month Day, Year]
*Last Revised:* [Month Day, Year]
At Overcomer Mental Health Services LLC, we believe patients should have clear information about the expected cost of their healthcare services.
Federal law, including the *No Surprises Act, provides certain protections against unexpected medical bills and requires healthcare providers to provide a **Good Faith Estimate (GFE)* to certain patients who are uninsured or who are not using insurance.
What is a Good Faith
A Good Faith Estimate is an estimate of the expected charges for healthcare services that are reasonably expected to be provided to you.
Depending on your situation, your estimate may include expected charges for services such as:
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Psychiatric evaluations
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Medication management visits
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Psychotherapy or counseling services
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Follow-up appointments
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Other behavioral health services
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Additional services that are reasonably expected and known at the time the estimate is prepare
A Good Faith Estimate is not a bill and is not a guarantee of the final cost of services.
Your actual charges may differ if your treatment needs, services, appointment frequency, or other circumstances change.
Who Can Receive a Good Faith Estimate?
Under the No Surprises Act, providers generally must provide a Good Faith Estimate to individuals who are:
• *Uninsured*, or
• *Not using insurance* to pay for their healthcare services.
If you have insurance and intend to use your insurance for services, your cost may instead depend on your insurance plan, deductible, copayment, coinsurance, authorization requirements, and other plan terms.
You may still request information about our expected charges before receiving services.