Good Faith Estimate (GFE) Disclosure
Notice to Uninsured and Self-Pay Clients under the No Surprises Act
Right to Receive a Good Faith Estimate: Under Section 2799B-6 of the Public Health Service Act, you have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers must give patients who do not have insurance, or who are not using insurance, an estimate of the bill for scheduled items or services.
Important Disclosures and Client Rights:
Advance Notice: You have the right to receive a written Good Faith Estimate at least one (1) business day before your scheduled medical service or item. You can also ask me, or any other provider you choose, for a Good Faith Estimate before you schedule an appointment.
Dispute Resolution: If you receive a bill from this practice that is at least $400 more than your written Good Faith Estimate, you have the legal right to dispute the bill through the federal patient-provider dispute resolution process.
Documentation: Make sure to save a copy or take a picture of your written Good Faith Estimate. It is an important baseline document for your financial records.
How Estimates are Provided for My Practice: > Because my standard practice fees and private pay structures are fully integrated into the Headway platform, your official, comprehensive Good Faith Estimate will be dynamically generated and made visible to you on Headway at the time of booking. This digital estimate will outline the exact cost-per-session for your specific initial evaluation or follow-up care before you finalize your appointment.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.
Financial Agreement & Patient Responsibility
Assignment of Benefits and Financial Responsibility: By scheduling an appointment, you explicitly authorize the assignment of insurance benefits, directing your insurance carrier to make payments directly to Headway for covered psychiatric services rendered. You grant permission to Headway to automatically charge your designated Payment Method on file for your specific cost-share amount immediately following each encounter.
You acknowledge that an insurance eligibility quote or cost estimate is not a guarantee of payment. You remain fully liable for the total cost of services should your insurance carrier ultimately deny the claim, apply the balance to a deductible, or if your coverage terminates. If you are operating under a Private Pay framework, you agree to the established practice fee schedule visible on the portal and acknowledge that payments are due in full at the time of session confirmation.
Furthermore, you acknowledge that your appointment time is reserved exclusively for your care. Failure to provide a minimum of 24 hours' advanced notice for a cancellation or modification will result in an automated $100 late cancellation fee charged to your payment method on file the following day. This fee is non-billable to third-party payers and must be resolved prior to booking future sessions.