You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost if:

• Do not have health insurance, or

• Choose not to use your insurance and pay out of pocket (self-pay).

At Rain Tree Mental Health:

• You can ask for a Good Faith Estimate at any time before you schedule, or when you schedule a non-emergency visit.

• We will provide a written estimate of the expected charges for your psychiatric evaluation and follow-up appointments, and any other reasonably expected services related to your care.

• Your Good Faith Estimate will be provided in writing (paper or electronic) and you can save it or take a picture for your records.

• A Good Faith Estimate is not a bill and not a contract. It shows our best estimate of the cost of your care based on the information we have at the time. Actual charges may be different if your treatment changes or you need additional services.

• If you receive a bill that is $400 or more above the amount listed on your Good Faith Estimate for the same provider and services, you may have the right to dispute the bill through a patient-provider dispute resolution process.

• For questions or more information about your right to a Good Faith Estimate, you can visit the federal No Surprises Act website at www.cms.gov/nosurprises or call 1-800-985-3059.