Model Disclosure Notice

“Right to Receive a Good Faith Estimate of Expected Charges”
Under the No Surprises Act

OMB Control Number 0938-1401 (expiration 05/31/2025)

Clients have the right to receive a “Good Faith Estimate” explaining how much their medical care will cost

Under the No Surprises Act, health care providers need to provide patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services. 

Clients have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. Please note, these services are not provided at Cultivate Counseling. Cultivate Counseling only provides individual, couples, and group therapy services provided either in person or via telemental health.

Health care providers should provide a Good Faith Estimate in writing at least one business day before a client’s medical service or item. Clients can also ask their health care provider, and any other provider they choose, for a Good Faith Estimate before they schedule an item or service. 

Cultivate provides session and service fees in our initial email with clients and in our Informed Consent and Financial Agreement, which clients must sign before their first session.

If the client receives a bill that is at least $400 more than their Good Faith Estimate, they can dispute the bill.

Clients should save a copy or picture of their Good Faith Estimate.

For questions or more information about client rights to a Good Faith Estimate, visitwww.cms.gov/nosurprises or email Cultivate Counseling at info@cultivateatlanta.com.