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YOUR RIGHTS UNDER THE NO SURPRISES ACT
Good Faith Estimate
If you do not have health insurance — or choose not to use it to pay for therapy services — you have the right to receive a written estimate of expected charges before your care begins.
01 — CLEAR, UPFRONT INFORMATION
What is a 'Good Faith Estimate?'
A Good Faith Estimate outlines the expected cost of the therapy services you schedule or request. It is available to those who do not have insurance and to those who have insurance but do not want a claim submitted for the requested services.
The estimate is not a contract and does not require you to receive services from Milton’s Place Counseling. Actual services or charges may change if your care needs change.
02 — WHEN TO EXPECT IT
When will I receive my estimate?
The delivery timeframe depends on when you schedule care or request your estimate.
01
Scheduled 3–9 Business Days in Advance
You will receive your estimate no later than one business day after scheduling.
02
Scheduled 10 or More Business Days in Advance
You will receive your estimate no later than three business days after scheduling.
03
Requested Before Scheduling
You will receive your estimate no later than three business days after your request.
If care is scheduled fewer than three business days in advance, federal rules do not require a Good Faith Estimate before the appointment.
For recurring therapy, one estimate may cover up to 12 months.
03 — YOUR BILLING RIGHTS
What if my bill is higher than the estimate?
If the billed charges from a provider or facility are at least $400 more than the amount listed in that provider or facility’s Good Faith Estimate, you may be eligible to use the federal patient-provider dispute resolution process.
Generally, you must begin the dispute within 120 calendar days of the date on the initial bill.
Save a copy of your Good Faith Estimate and your bill. Beginning a dispute will not affect the quality of care you receive.
$400+
Above the estimate may qualify for federal dispute review.
120
Calendar davs from the initial bill to begin the federal process.
04 — WE ARE HERE TO HELP
Request a Good Faith Estimate
Milton’s Place, PLLC, doing business as Milton’s Place Counseling, provides Good Faith Estimates in writing to qualifying uninsured and self-pay clients.
To request an estimate before scheduling, call (734) 544-5189 or email billing@miltonsplacecounseling.com.
Please do not include detailed clinical or health information in an unencrypted email.
QUESTIONS ABOUT YOUR FEDERAL RIGHTS?
Visit CMS Medical Bill Rights or call the No Surprises Help Desk at 1-800-985-3059.