Good Faith Estimate

Good Faith Estimate Provision of the No Surprises Act

As required by the No Surprises Act, we are providing you with the following information regarding your rights to receive a Good Faith Estimate for the costs of any healthcare services or products you receive. The No Surprises Act is a federal law designed to protect patients from unexpected medical bills and requires healthcare providers to give patients an estimate of the cost for non-emergency services in advance.

Good Faith Estimate of Costs

You have the right to receive a Good Faith Estimate for the total cost of your counseling or psychotherapy services if you are uninsured or choose to forgo use of insurance benefits for treatment. This estimate will include the expected charges for the services provided, including any known or anticipated fees for specific services. The estimate will be provided based on the information available at the time of the request.

• What is a Good Faith Estimate?

A Good Faith Estimate is an estimate of the total expected cost for any healthcare services (medical and behavioral health) that you will receive from and healthcare provider. For counseling or psychotherapy, this estimate will be based on the information we know at the time of your request, including the type of services, frequency of sessions, and any potential additional costs for materials or procedures.

• How to Request a Good Faith Estimate:

You may request a Good Faith Estimate by contacting LSG Counseling Services, PLLC before receiving services. We will provide you with an estimate that reflects the expected costs, which may include charges for initial assessments, regular counseling sessions, and other necessary services related to your treatment.

• What Happens if the Actual Charges Differ from the Estimate?

If the actual charges for the services you receive are different from the Good Faith Estimate, you will be notified of any significant changes as soon as possible. It’s important to note that while the estimate is based on the information available to us, unforeseen circumstances or additional services required during the course of treatment may lead to a variance in the final cost.

• Disputing Charges:

If you believe that the final cost of any healthcare service provider or facility exceeds at least $400 of the Good Faith Estimate you received, you have the right to dispute that bill.

You have the right to receive a Good Faith Estimate for any covered non-emergency services from LSG Counseling Services, PLLC, and we will provide you with the best information available regarding your financial obligations.

For further assistance with obtaining a Good Faith Estimate or to discuss financial concerns regarding your treatment, please contact us at:

This provision is intended to comply with the No Surprises Act and help you understand the financial aspects of your treatment. If you have any questions regarding your estimate or the services provided, please do not hesitate to contact us. For more information on the Good Faith Estimate provision of the No Surprise Act visit https://www.cms.gov/medical-bill-rights.