GOOD FAITH ESTIMATE NOTICE

Required by the No Surprises Act for all self-pay and uninsured clients. This must be prominently displayed on your website. Create a standalone page AND add a brief version to your Services page and your booking page.

Your Right to a Good Faith Estimate
Required by the No Surprises Act, effective January 1, 2022
Under federal law you have the right to receive a Good Faith Estimate of expected charges before receiving healthcare services.

What This Means For You
If you are uninsured, or if you have insurance but choose not to use it for your sessions with Dr. Mariya, you are entitled to receive a written Good Faith Estimate of the expected cost of services before your first appointment.

The Good Faith Estimate will include the expected cost of psychological services based on your anticipated treatment. Because therapy is an ongoing and individualized process, the estimate will reflect a reasonable range of sessions and associated costs for a 12-month period.

Good Faith Estimates are not a contract. Actual charges may differ based on your individual treatment needs. If your actual charges are $400 or more above the amount listed in your Good Faith Estimate you have the right to dispute the bill.

How to Request a Good Faith Estimate
A Good Faith Estimate will be provided to all uninsured and self-pay clients before the first session. If you would like to request a Good Faith Estimate before scheduling please contact:
hi@drmariyapsyd.com
www.drmariyapsyd.com

Current Fees
Individual Therapy: $225 per 50-minute session
Ketamine Assisted Psychotherapy: $600 per 3-hour session plus separate medical evaluation fee
Group Therapy: Approximately $135 per session, details announced upon launch

Dispute Resolution
If you receive a bill that is $400 or more above your Good Faith Estimate you may contact the U.S. Department of Health and Human Services to learn about the dispute resolution process at cms.gov/nosurprises or by calling 1-800-985-3059.

For questions about your Good Faith Estimate please contact Dr. Mariya, PsyD at hi@drmariyapsyd.com.

ALSO ADD THIS SHORT NOTICE TO YOUR BOOKING PAGE AND SERVICES PAGE:
Under the No Surprises Act you have the right to receive a Good Faith Estimate of expected charges before your first session. For more information or to request an estimate please contact hi@drmariyapsyd.com or visit our Good Faith Estimate page.