Matthew Love, Psy.D., LLC
215 Main St, 2nd Floor
Westport, CT 06880
Notice Regarding the No Surprises Act and Your Right to a Good Faith Estimate
This notice describes your right to receive a Good Faith Estimate of expected charges for psychological services. Please review it carefully.
Effective Date of This Notice
This notice went into effect on January 1, 2022.
I. Your Rights Under the No Surprises Act
Under the No Surprises Act, which became effective January 1, 2022, you have the right to receive a Good Faith Estimate explaining how much your psychological services will cost.
The law requires health care providers to give patients who do not have insurance, or who choose not to use their insurance, an estimate of the expected charges for scheduled services, including psychological assessment, psychotherapy, and other psychological services.
II. When You Are Entitled to a Good Faith Estimate
You are entitled to a Good Faith Estimate if:
- You do not have health insurance coverage of any kind (including commercial insurance, HMOs, union health plans, or government health plans such as Medicare, Medicaid, or TRICARE).
- You have health insurance but choose not to use your insurance benefits and will pay for services out-of-pocket.
- You are inquiring about the cost of services before scheduling an appointment.
III. My Responsibilities
I am required by law to:
- Provide you with a Good Faith Estimate in writing before you receive scheduled services, or upon your request.
- Make this notice available prominently in my office and on my website.
IV. What the Good Faith Estimate Includes
The Good Faith Estimate will include:
- My name, National Provider Identifier (NPI), and Tax Identification Number (TIN).
- A description of the primary psychological service(s) being scheduled or requested.
- An itemized list of expected services and charges.
- The date(s) the service(s) are expected to be provided.
- Applicable diagnosis codes, if known.
- Any disclaimers required by law.
V. Important Information About the Good Faith Estimate
Please understand the following:
- The Good Faith Estimate is an estimate only. Actual charges may differ from the estimate if the scope of services changes during the course of your treatment.
- The Good Faith Estimate is not a contract and does not obligate you to obtain services from me.
- The Good Faith Estimate does not include any unknown or unforeseen services that may arise during treatment. If additional services are recommended, I will discuss them with you and provide updated cost information.
- Because the nature of psychological treatment often depends on factors that emerge over time, the actual duration and course of treatment may vary from initial estimates.
VI. Your Right to Dispute a Bill
If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill.
You may initiate the dispute resolution process within 120 calendar days of the date on the original bill. Initiating a dispute will not adversely affect the quality of care you receive. Make sure to save a copy of your Good Faith Estimate for your records.
VII. For More Information
For questions or more information about your right to a Good Faith Estimate, you may:
- Contact me at (203) 293-6081 or mlove@matthewlovepsyd.com
- Visit the Centers for Medicare & Medicaid Services website at www.cms.gov/nosurprises
- Call (800) 985-3059