Your Right to a Good Faith Estimate

1. Standard CMS notice (verbatim)

Source: Centers for Medicare & Medicaid Services (CMS) standard disclosure language under the No Surprises Act, 45 CFR §149.610.

2. Who is entitled to a Good Faith Estimate

Under 45 CFR §149.610, the following individuals are entitled to a written Good Faith Estimate ("GFE") from us before scheduled non-emergency services:

• Uninsured individuals — anyone without health insurance.
• Self-pay individuals — anyone with health insurance who is not using their insurance to pay for the services from us. Because couples therapy is generally not covered by health insurance (see our Insurance page for the honest answer), most clients receiving couples therapy from PCG fall into this category, even when they hold a health insurance policy.

A GFE is not required when you are using insurance and the practice is in-network for that insurance product. In that case, your insurer's "Advanced Explanation of Benefits" (AEOB) under the same law gives you the equivalent disclosure.

3. What the Good Faith Estimate contains

Your GFE will include, per 45 CFR §149.610(c):

• Your name and date of birth.
• A clear, itemized list of the services we expect to provide (CPT/HCPCS codes), including service descriptions and per-service charges.
• The diagnosis codes (ICD-10) we expect to use for billing, where reasonably knowable in advance.
• The expected service-period dates, frequency, and total number of sessions where reasonably foreseeable.
• The total expected cost across the period covered by the estimate.
• The provider's National Provider Identifier (NPI) and Tax ID.
• Service location: 301 N. Lake Ave, STE 600, Pasadena, CA 91101 (and/or telehealth, where applicable).
• A clear written disclaimer that the estimate is not a contract, that actual charges may differ if the course of care changes, and that you may dispute charges that exceed the estimate by $400 or more.
• The CMS standard notice language (see Section 1).

4. When you'll receive it

Per 45 CFR §149.610(b):

• If services are scheduled at least 3 business days in advance: the GFE will be provided to you no later than 1 business day after scheduling.
• If services are scheduled at least 10 business days in advance: the GFE will be provided to you no later than 3 business days after scheduling.
• If you request a GFE without scheduling services: the GFE will be provided to you within 3 business days of your request.

You can request a GFE at any time by contacting our office (see Section 8). You may also request a GFE before scheduling — to compare expected costs across providers — and we'll provide one without obligation to schedule.

5. Sample expected charges (Pasadena Clinical Group)

The figures below are illustrative ranges for our typical services. Your actual GFE will be specific to your case. These ranges are aligned with our public Insurance page (see Insurance) and are reviewed annually.

Sliding-scale, Prepare/Enrich, and Bringing-Baby-Home assessment fees are quoted separately and follow the same GFE process.

6. Your right to dispute a bill ($400 rule)

If you receive a final bill from us that is at least $400 more than your most recent Good Faith Estimate, you have a federally protected right to dispute the bill through the CMS Patient-Provider Dispute Resolution (PPDR) process under 45 CFR §149.620.

How the CMS dispute process works:

1. File within 120 days of receiving the final bill. You file with CMS, not with the provider directly. There is a $25 administrative fee, which CMS may waive based on financial hardship.
2. CMS assigns an independent dispute resolution entity (IDRE) — a neutral third party — to review your case. CMS notifies the provider of the dispute.
3. Both parties submit information — the patient's GFE, the final bill, supporting documentation. The IDRE reviews.
4. The IDRE issues a binding determination within 30 business days of selection. The amount the provider may collect is generally limited to the amount on the GFE plus $400 unless the IDRE determines the additional charges were credibly justified.
5. Initiate disputes via the federal NSA portal at cms.gov/nosurprises, or call the No Surprises Help Desk at 1-800-985-3059.

You will not be retaliated against for initiating a dispute. We will not refuse care, charge differently, or otherwise penalize you for exercising your rights under the No Surprises Act.

7. Save your Good Faith Estimate

Per CMS guidance, you should save a copy or picture of your GFE in case you later need it for a dispute. We will also retain a copy in your file. You may request a duplicate at any time at no charge by contacting us.

8. How to request a Good Faith Estimate

By phone: (626) 354-6440
By email: office@pasadenaclinicalgroup.com
By mail: Pasadena Clinical Group, Attn: Healthcare Coordinator, 301 N. Lake Ave, STE 600, Pasadena, CA 91101

We will respond within the timelines in Section 4 above. Estimates are provided in writing (electronically by default; on paper on request).

9. Limits and updates

A Good Faith Estimate is an estimate, not a contract. The actual cost may differ if the clinical course changes — additional sessions, a different modality, an unforeseen need for a longer session. If a material change to the expected services arises, we will issue a revised GFE before the change takes effect, when feasible.

Convening providers (where one provider coordinates services across multiple providers for a single episode of care) and co-providers requirements under the No Surprises Act do not apply to most of our outpatient psychotherapy services because the practice does not bundle services across multiple separately-billing providers. Where they do apply (rare in this practice), we follow CMS rules for convening-provider GFE coordination.

10. Questions and contact

Questions about your GFE rights, this disclosure, or how to request an estimate:

Pasadena Clinical Group — Healthcare Coordinator
301 N. Lake Ave, STE 600
Pasadena, CA 91101
Tel: (626) 354-6440
Email: office@pasadenaclinicalgroup.com

For federal questions about the No Surprises Act, contact CMS at 1-800-985-3059 or visit cms.gov/nosurprises.