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Good Faith Estimate (GFE)

KWIK PSYCH CLINICS PLLC (KwikPsych)

Your Right to Receive a Good Faith Estimate

If you don’t have certain types of health insurance, or if you choose not to use your insurance for services at Kwik Psych Clinics PLLC (“KwikPsych”), you have the right to receive a Good Faith Estimate of the expected costs of your care.

A Good Faith Estimate is a written estimate that shows the expected charges for mental health services you may receive. It is not a bill and not a contract.

Who this applies to

You can receive a Good Faith Estimate if:

  • You do not have health insurance, or
  • You have insurance but choose not to use it for services at KwikPsych (self‑pay), or
  • You are asking about the cost of services before you decide whether to schedule.
     

When you can get a Good Faith Estimate

If you are uninsured or self‑pay, you can request a Good Faith Estimate at any time.

You are also entitled to a Good Faith Estimate:

  • When you schedule a non‑emergency service at least 3 business days in advance.
  • Before you schedule, if you ask for an estimate of costs.

Federal rules say:

  • If you schedule a service at least 3 business days before the visit, KwikPsych will give you a written Good Faith Estimate within 1 business day after scheduling.
  • If you schedule a service at least 10 business days before the visit, KwikPsych will give you a written Good Faith Estimate within 3 business days after scheduling.
  • If you request a Good Faith Estimate before scheduling, we will give it to you within 3 business days of your request.

You can ask to receive your estimate by mail, by secure email/portal, or handed to you in person (for in‑office visits).

What will be in your Good Faith Estimate

Your Good Faith Estimate will include:

  • Your name and basic contact information
  • Our clinic name and contact information
  • A description of the mental health services we reasonably expect to provide
  • An itemized list of expected services (for example, one initial psychiatric evaluation + a number of follow‑up visits) and the expected charges for each
  • A total estimated cost for the period of care described in the estimate

Because mental health care is individualized and may change over time, your Good Faith Estimate may list a range or number of visits (for example, “12 weekly therapy sessions”) based on what is reasonably expected at the time.

Limits of a Good Faith Estimate

  • The Good Faith Estimate is based on information known at the time it is created.
  • It does not include any services that you schedule separately later, or any unexpected changes in your care.
  • Your actual treatment plan, number of visits, and total costs may be more or less than the estimate, depending on your needs and preferences.

We will talk with you about your goals and needs on an ongoing basis and can update your estimate if your plan of care changes.

If your bill is higher than your Good Faith Estimate

If you receive a bill that is at least $400 more than the total expected charges in your Good Faith Estimate for KwikPsych, you may have the right to dispute the bill.

You can:

  • Contact us first to review the bill and your Good Faith Estimate.
  • Ask us to correct any errors on the bill or estimate.
  • Ask us if there are payment plan or financial hardship options.

You may also start a patient‑provider dispute resolution process with the U.S. Department of Health and Human Services (HHS):

  • You must start the dispute process within 120 calendar days from the date on the original bill.
  • There is currently a $25 administrative fee to use this process (set by HHS and subject to change).

 

For more information about your right to a Good Faith Estimate or the dispute process:

Visit: www.cms.gov/nosurprises/consumers
Email: FederalPPDRQuestions@cms.hhs.gov
Call: 1‑800‑985‑3059

KwikPsych contact information

For billing questions, payment arrangements, or to request a Good Faith Estimate, contact:

Phone: 737‑367‑1230
Email: info@kwikpsych.com
Website: kwikpsych.com

Please keep a copy of your Good Faith Estimate in a safe place. You may need it if you receive a bill you did not expect or if you decide to dispute a bill later.