No Surprises Act

Your Right to Receive a Good Faith Estimate of Expected Charges

Under the No Surprises Act, health care providers are required to provide patients who do not have insurance or who choose not to use their insurance with an estimate of the expected costs for medical and mental health services.

You have the right to receive a Good Faith Estimate explaining the anticipated cost of your mental health care before you begin services or upon request.

A Good Faith Estimate includes the expected charges for reasonably anticipated services provided by Grounded Mental Health, LLC. It does not include costs that may arise from unforeseen circumstances or additional services that become necessary during the course of treatment.

If you are:

Paying for services without using insurance (self-pay), or
Choosing not to submit claims to your insurance,

you may request a Good Faith Estimate before scheduling services or at any time during your treatment.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill through the U.S. Department of Health and Human Services (HHS).

For questions or to request a Good Faith Estimate, please contact:

Grounded Mental Health, LLC

Email: info@firstresponderstherapy.com

Phone: (813) 625-6620

For more information about your rights under the No Surprises Act or the Good Faith Estimate process, visit www.cms.gov/nosurprises.