Your Right to a Good Faith Estimate
Effective August 31, 2026
You have the right to receive a written estimate of what your care will cost before you receive it.
What this means
Under the federal No Surprises Act, health care providers must give patients who do not have insurance, or who are not using insurance, an estimate of the expected charges for medical services.
- You have the right to receive a Good Faith Estimate explaining how much your care will cost.
- You are entitled to a Good Faith Estimate in writing at least one business day before your appointment. You can also ask for one at any time, before you schedule.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
Who receives one
Harmony Health provides a Good Faith Estimate to every patient who is uninsured, and to every insured patient who chooses not to submit a claim to their health plan for a given service. If you are using insurance and we are in network with your plan, your cost is determined by your plan's benefits rather than by this estimate.
What the estimate includes
Your estimate lists the services reasonably expected for your care, such as the initial psychiatric evaluation and the follow-up visits anticipated over the following twelve months, with the expected charge for each. It is based on the information known at the time it is prepared.
A Good Faith Estimate is an estimate, not a contract, and not a bill. It does not obligate you to receive any of the services listed.
Your actual cost may differ if your care changes. If your treatment plan changes in a way that meaningfully affects cost, you will receive an updated estimate.
What is not included
The estimate covers services provided by Harmony Health only. It does not include charges from other providers or facilities, such as laboratory services, imaging, a hospital, or a therapist in another practice. Those providers are required to give you their own Good Faith Estimate on request.
Current self-pay rates
These are the rates for patients who are uninsured, out of network, or choosing not to use insurance for a visit.
- Initial intake visit — $250
- Follow-up visit — $125
If you are using insurance and the practice is in network with your plan, your cost is set by your plan's benefits rather than these rates. A superbill is provided after each session so out-of-network patients can submit a claim for reimbursement.
How to request one
Ask at any time by email at diloram.kamilova@
If you are billed more than your estimate
If you are billed at least $400 more than your Good Faith Estimate, you may start a patient-provider dispute resolution process with the U.S. Department of Health and Human Services within 120 calendar days of the date on your bill. There is a fee to use the process. If the reviewer agrees with you, you will pay the amount on the estimate. If the reviewer agrees with the provider, you will pay the higher amount.
To learn more or start a dispute, visit cms.gov/nosurprises or call 1-800-985-3059.
Questions
If anything here is unclear, ask. Cost should not be the reason you delay care, and it is a reasonable thing to discuss directly.