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GOOD FAITH ESTIMATE 

Your right to an estimate of expected charges.

If you are choosing not to use insurance, you have the right to receive a Good Faith Estimate explaining how much your care is expected to cost.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your mental health care. It is based on information that is 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. You may contact Jung Psych Services to inform them that the billed charges are higher than the Good Faith Estimate. You can request to update the billl 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 US Department of Health and Human Services (HHS). If you chooose to use the dispute resolution process, you must start the dispute process within 4 120 calendar days (about 4 months) of the date on the original bill. 

What to know

  • You may request a Good Faith Estimate before scheduling care.
  • If you schedule care in advance, an estimate may also be required within specific timeframes.
  • The estimate is based on information available at the time and may not include unexpected costs.
  • If a provider’s bill is at least $400 more than its Good Faith Estimate, you may be eligible to dispute the charge.
  • There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will be required to pay the price on this Good Faith Estimate. If the agency disagrees with you, and agrees with Jung Psych Services, you will have to pay the higher amount.

Questions?
Contact Jung Psych Services at
(480) 775-6423
counselor@AudreyJung.com

Contact

GOOD FAITH ESTIMATE NOTICE

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing, upon request or at the time of scheduling health care items and services. This notice informs individuals who are uninsured, or who are enrolled in coverage but do not plan to submit a claim through that coverage, about the expected charges for certain health care items and services. A Good Faith Estimate must be provided within 3 business days of a request. For scheduled care, the estimate must be provided within 1 business day after scheduling when the service is scheduled at least 3 business days in advance, or within 3 business days after scheduling when the service is scheduled at least 10 business days in advance.

Under current law, health care providers must give patients who do not have insurance—or who do not plan to use insurance to pay for their care—a Good Faith Estimate of expected charges for scheduled or requested items and services.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your mental health care. It is based on information that is 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.

You may contact Jung Psych Services to inform them that the billed charges are higher than the Good Faith Estimate. You can request to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

If a provider’s bill is at least $400 more than the amount listed in the Good Faith Estimate, you may be eligible to start a federal patient-provider dispute resolution process. The process must generally be started within 120 calendar days of the date on the initial bill.

A $25 nonrefundable administrative fee applies. An independent third party will review the Good Faith Estimate, the bill, and supporting information to determine the appropriate amount you must pay. You and the provider may also continue to negotiate the bill during the dispute process.

To learn more or begin the dispute process, visit cms.gov/medical-bill-rights/help/dispute-a-bill or call the No Surprises Help Desk at 1-800-985-3059.