STEVEN M. HARRIS, PhD
1400 Quail St. No. 210, Newport Beach, CA 92660 * 714.290.1506
Licensed Psychologist, PSY13471, NPI 1487673927
Center for Depth Psychology, Inc. (Tax ID No. 20-2973057, NPI 1467762450)
Good Faith Estimate
Dear Patient:
Effective January 1st, 2022, you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost, as required by a provision in the No Surprises Act (H.R.133). Under the law, healthcare providers need to give patients who do not have insurance, or who are not using insurance, an estimate of the bill for medical items and services.
Specifically:
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items.
- Your healthcare provider must give you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your healthcare provider, for a Good Faith Estimate.
- If you receive a bill that is at least $400.00 more than your Good Faith Estimate, you can dispute the bill.
Required Disclaimers
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information 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. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed 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 $25 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 www.cms.gov/nosurprises or call 1-877-696-6775. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-877-696-6775.
1400 Quail St. No. 210, Newport Beach, CA 92660 * 714.290.1506
Licensed Psychologist, PSY13471, NPI 1487673927
Center for Depth Psychology, Inc. (Tax ID No. 20-2973057, NPI 1467762450)
Good Faith Estimate
Dear Patient:
Effective January 1st, 2022, you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost, as required by a provision in the No Surprises Act (H.R.133). Under the law, healthcare providers need to give patients who do not have insurance, or who are not using insurance, an estimate of the bill for medical items and services.
Specifically:
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items.
- Your healthcare provider must give you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your healthcare provider, for a Good Faith Estimate.
- If you receive a bill that is at least $400.00 more than your Good Faith Estimate, you can dispute the bill.
Required Disclaimers
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information 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. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed 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 $25 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 www.cms.gov/nosurprises or call 1-877-696-6775. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-877-696-6775.