No Surprises Act

Good Faith Estimate

Your right to an estimate of expected costs

Under the law, health care providers need to give patients who don't have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychiatric and mental health care.

• You 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 the visit itself and any expected follow-up care.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your service. You can also ask your provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

Our self-pay fees

For reference, our standard private-pay fees are:

• Comprehensive Psychiatric Consultation (60–75 minutes) — $250
• Concierge Follow-Up Session (30 minutes) — $150
• Medication Management (15 minutes) — $100
• Psychotherapy Session (50 minutes) — $250

Your individualized Good Faith Estimate will reflect the services expected in your care. To request one, contact support@kailingconcierge.com.

Questions

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.