Good Faith Estimate Notice

You are entitled to receive a Good Faith Estimate of what the charges could be for therapy services provided to you. It is not possible for a therapist to know, in advance, how many therapy sessions may be necessary or appropriate for you, but you are entitled to an estimate of the cost of services provided based on information known at the time that the estimate was created. Your total cost of services will depend on the number of therapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.

The estimate is not a contract and does not obligate you to obtain any services from Cornell & Associates Marriage and Family Therapy, nor does it include any unknown or unexpected services costs that may arise during treatment. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

You could be charged more than the Good Faith Estimate if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. You may contact the health care provider or facility related to your therapy sessions 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 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 cms.gov/nosurprises 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 cms.gov/nosurprises or call 800-368-1019.

Keep a copy of the Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.