Your Rights & the No Surprises Act

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At 406 Therapeutics LLC, I want you to feel informed, respected, and empowered—both financially and emotionally. As part of the No Surprises Act, you have the right to receive a Good Faith Estimate that explains the expected cost of your mental health services.

GOOD FAITH ESTIMATE (GFE) - For Services Under the No Surprises Act

Under the law, health care providers are required to give clients who do not have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy. You have the right to receive a Good Faith Estimate explaining how much your mental health services may cost.

Your Rights Under the Good Faith Estimate

· You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency mental health services.

· You may ask your therapist for a Good Faith Estimate before scheduling a service, or at any time during your treatment.

· If you receive a bill that is $400 or more above your Good Faith Estimate, you may dispute the bill.

· Make sure to save a copy or picture of your Good Faith Estimate.

Good Faith Estimate Disclaimer

The following is only an estimate of the cost of services. Your actual total cost may vary depending on:

the number of sessions you choose to attend,

changes in frequency of sessions,

changes in treatment needs or goals,

crisis or additional sessions requested by you.

Therapy is highly individualized, and the duration of treatment varies by client.

Dispute Resolution

If you receive a bill that is at least $400 more than this Good Faith Estimate, you may start a dispute process with the U.S. Department of Health and Human Services (HHS).

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit: www.cms.gov/nosurprisesor call 1-800-985-3059.