Your Right to a Good Faith Estimate

Under the federal No Surprises Act, you have the right to receive a Good Faith Estimate (GFE) of expected charges for medical services if you are uninsured or if you choose not to use insurance. This applies to all patients of Peter Pham, PMHNP-BC.

What is a Good Faith Estimate?

A Good Faith Estimate is a written estimate of the expected charges for items and services you may receive. We will provide a GFE to you:

  • When you schedule services at least 3 business days in advance, we will provide your GFE no later than 1 business day after scheduling.
  • When you schedule services at least 10 business days in advance, we will provide your GFE no later than 3 business days after scheduling.
  • Whenever you request one, even before scheduling.

Your GFE will include:

  • The expected charges for the items and services you are scheduled to receive.
  • A list of items and services associated with your visit (for example: psychiatric diagnostic evaluation, medication management visit, therapy session if provided).
  • A diagnosis code, if known.
  • The provider name and license/NPI information.

If you receive a bill that is at least $400 more than your Good Faith Estimate

You can dispute the bill through the federal patient-provider dispute resolution process. You must start the dispute process within 120 calendar days of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will pay the price on your Good Faith Estimate. If the agency disagrees with you and agrees with the provider, you will pay the higher amount.

To learn more or start a dispute, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Sample charges (current self-pay rates)

Service Rate
Initial psychiatric evaluation (60 min) $200
Follow-up medication management (25–30 min) $100
Extended follow-up (45 min) $150

These are the current self-pay rates. Your individual Good Faith Estimate may include additional items or services depending on the clinical situation.

Make sure to save a copy of your Good Faith Estimate

Keep your Good Faith Estimate in a safe place. You may need it if you are billed a higher amount.

Questions?

Contact us at info@blackonyx.care or (714) 844-5541.

For more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.