Right to a Good Faith Estimate Form

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost for any non-emergency items or services. 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 bill for medical items and services.
If you are considering changing therapists, TALK TO YOUR CURRENT THERAPIST about your concerns. Trust us. They won’t be offended, their feelings will not be hurt and they won’t be upset with you. ​If you need help initiating that conversation, you can complete this form to make your therapist aware of your concerns. The information will be shared with your therapist and they discuss options and facilitate the transfer for you.
*Please do not register as a new patient. The new chart will be flagged as a duplicate, deleted and re-routed back to your current therapist. Our office staff cannot help you change providers.