Notice to Uninsured and Self-Pay Patients – Good Faith Estimate Available

Under the No Surprises Act, you have the right to receive a Good Faith Estimate explaining how much your medical and mental health care will cost.

If you are uninsured or choose not to use your insurance for services at our clinic, you are entitled to receive a Good Faith Estimate for the total expected cost of any non-emergency services, including psychiatric evaluations, therapy sessions, medication management, and other related services.

What You Should Know:

• You have the right to request a Good Faith Estimate in writing at least 1 business day before your scheduled service or upon request.

• The estimate will include expected charges for the services you will receive.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill through the Patient-Provider Dispute Resolution (PPDR) process.

How to Request a Good Faith Estimate:

To request a Good Faith Estimate, please contact our office:

Phone: 540-701-5559

Email: info@cipclinic.com

Website: www.cipclinic.com

We are happy to answer your questions and provide you with a written estimate upon request or scheduling.