Good Faith Estimate (No Surprises Act)

Effective Date: November 2025

Under federal law (the No Surprises Act), clients who don’t have insurance or who are not using insurance have the right to receive a Good Faith Estimate (GFE) explaining the expected cost of non-emergency services.

At Common Ground Therapy & Wellness PLLC, we believe in being upfront and clear—no surprise bills.

What Is a Good Faith Estimate?

  • A written estimate of the total expected charges for services you’re likely to receive.
  • Provided before your first session (and anytime you ask for one).
  • Based on information known at the time—your actual costs may change if your treatment plan changes, but we’ll keep you updated.

Who Gets a GFE?

  • Clients who are self-pay (uninsured or choosing not to use insurance).
  • Clients who request a GFE at any time.

Your Rights

  • You can receive a GFE in writing before services.
  • Keep a copy or photo of your GFE for your records.
  • If you get a bill that is $400 or more above your GFE for the same services, you may be able to dispute the bill through the Patient-Provider Dispute Resolution process.

What’s Included in a GFE

  • Service descriptions (e.g., individual psychotherapy)
  • Estimated frequency/duration (e.g., weekly, bi-weekly)
  • Per-session rates and the total estimated cost for a selected time frame
  • Any additional mutually-agreed fees (e.g., late cancellation/no-show)

Typical Services & Self-Pay Rates

(Update the amounts below to match your current fees.)

  • Initial intake session (53–60 min): $225
  • Standard therapy session (53–60 min): $200
  • Late cancellation/no-show (full fee): $200

Example Estimates (for planning)

These examples are for illustration only. Your GFE will reflect the plan you and your clinician discuss.

  • Weekly therapy for 12 weeks at $200 per 53–60 min session:
    12 sessions × $200 = $2,400
  • Bi-weekly therapy for 3 months at $200 per 53–60 min session:
    6 sessions × $200 = $1,200
  • Monthly therapy for 6 months at $200 per 53–60 min session:
    6 sessions × $200 = $1,200

Note: Frequency and duration of therapy are collaborative and may change based on your goals and preferences. If your plan changes, you can request an updated GFE at any time.

Requesting or Updating Your GFE

To request a Good Faith Estimate—or an update—email us at info@commongroundtherapywellness.com. We’ll provide a written estimate in a timely manner and answer any questions you have.

If Your Bill Exceeds Your GFE

If you receive a bill that’s at least $400 more than your GFE for the same services and timeframe, you can dispute the charge. Keep a copy of your GFE and visit the Centers for Medicare & Medicaid Services for instructions on the dispute process:

https://www.cms.gov/nosurprises

Important Notes

  • This GFE is not a contract and does not obligate you to receive services.
  • It reflects expected charges for non-emergency services only.
  • For privacy and security, please use our contact form or email for general questions, and our secure client portal for clinical communication.

Questions about estimates or self-pay rates? Email info@commongroundtherapywellness.com.