Good Faith Estimate Notice

Your Right to Receive a Good Faith Estimate

‍

Under the federal No Surprises Act, you have the right to receive a Good Faith Estimate (GFE) explaining how much your mental-health care will cost.

This law protects clients who do not have insurance or choose not to use insurance for their care.
You have the right to receive a written estimate of expected charges before you receive any non-emergency services.

What Is a Good Faith Estimate?

‍

A Good Faith Estimate outlines the expected costs of services reasonably known at the time the estimate is created.
It is not a bill, and the actual charges may vary depending on your specific needs, changes in treatment, or the frequency of sessions.

Your GFE will include:

• Your name and date of birth
  
• The name of your provider
  
• A list of expected services (for example: individual therapy, couples therapy, or assessment)
  
• The CPT code for each service (e.g., 90837 – Individual Therapy, 60 min)
  
• The expected fee per session and total estimated cost over the agreed-upon period of care
  
• The provider’s contact information and signature
  

Typical Session Fees at OtherKind Health

‍

‍

These are estimates only. Your total cost depends on the number of sessions, your individualized treatment plan, and any changes in goals or frequency.

‍

If You Receive a Bill That’s Higher Than Your Estimate

‍

If you receive a bill $400 or more higher than your Good Faith Estimate, you may dispute the charge.

You can:

1. Contact us first to discuss any difference or updated care needs.
   
   
2. Start a dispute resolution process with the U.S. Department of Health and Human Services (HHS).
   
   
   • You must submit your request within 120 days of receiving the bill.
     
   • There is a small administrative fee (set by HHS).
     
   • If the agency determines the billed amount exceeds your estimate by more than $400 without valid reason, the charge may be reduced.
     
     

For more information or to start a dispute, visit: https://www.cms.gov/nosurprises

Questions or Requests

‍

You may request a personalized Good Faith Estimate at any time—before, during, or after establishing care.

OtherKind Health Inc.
26 Court St, Suite 409
Brooklyn, NY 11242

‍
📧 admin@otherkind.health
📞 (347) 695-8715‍