Good Faith Estimate Policy

In compliance with the No Surprises Act (2022)

Your Right to a Good Faith Estimate

As a client of Abide in the Vine Counseling, PLLC, you have the right to receive a written Good Faith Estimate (GFE) explaining the cost of your care. This estimate helps ensure transparency and empowers you to make informed financial decisions about your treatment.

Who Is Eligible?

The Good Faith Estimate applies to clients who:

• Are uninsured, or

• Are self-pay (not submitting claims to insurance),

• And are scheduling non-emergency services.

What Is Included in a GFE?

Your estimate will include:

• The provider’s name and credentials

• A description of the services expected (i.e., intake session, ongoing therapy, assessments)

• Frequency and duration of services, if known

• Estimated total cost of services over a 12-month period (or for a specified timeframe)

• Disclaimers regarding variability of treatment and your rights

When Will I Receive It?

You will receive a written Good Faith Estimate:

• Before your first scheduled appointment, and

• Upon request, at any point during treatment

If your services extend or change, a revised estimate may be issued.

Please Note:

This estimate reflects expected charges based on the information available at the time. It does not bind you to receive services or obligate you to a certain number of sessions. You may end services at any time.

Dispute Process:

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to initiate a dispute resolution process through the U.S. Department of Health and Human Services. You must start the dispute within 120 calendar days of receiving the bill.

To learn more or begin a dispute, visit:

www.cms.gov/nosurprises

Questions or Requests?

To ask questions or request a Good Faith Estimate for services, please email:

abideinthevinecounseling@gmail.com