Good Faith Estimate Notice

Effective Date: 01/01/2022

At Firm Foundation Counseling, we are committed to transparency about the cost of your mental health care. If you are receiving services as a self-pay patient or are uninsured, you have the right to receive a Good Faith Estimate of the expected charges for the mental health services you may receive.

What is a Good Faith Estimate?

A Good Faith Estimate is an itemized written estimate of the costs of the services, including therapy sessions, assessments, or other care, that you are scheduled to receive. It helps you understand the expected fees so you can plan accordingly.

How to Request a Good Faith Estimate

You may request a Good Faith Estimate before your first appointment or anytime during treatment by contacting us at:

• Phone: (574)-400-7685

• Email: info@firmfoundationcounselingllc.com

We will provide the estimate in writing within [3 business days] of your request.

Your Rights

• You have the right to receive a Good Faith Estimate before scheduling or receiving services.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the charge. Instructions on how to dispute will be provided with your bill.