GOOD FAITH ESTIMATE (NO SURPRISES ACT)

Last updated: January 2025

Under the No Surprises Act, patients who are uninsured or who choose to self-pay are entitled to receive a Good Faith Estimate (GFE) of expected medical charges.

1. Your Rights

You have the right to receive an estimate of costs before your appointment.

2. What’s Included

Your Good Faith Estimate may include:

• Initial psychiatric evaluation fees

• Follow-up medication management costs

• Additional services (if applicable)

3. Requesting a GFE

You may request a Good Faith Estimate at any time by contacting:
hello@balancedbrainnp.com

4. Disputing Charges

If your bill is $400 or more above the GFE, you may dispute it under federal law.

5. Additional Information

Your GFE is based on expected services and may change based on clinical findings.