Your Right to a Good Faith Estimate

​

Effective January 1, 2022 — No Surprises Act (Public Law 116-260)

Last Revised: February 13, 2026​

​

You have the right to receive a "Good Faith Estimate" explaining how much your health care will cost.

Under the No Surprises Act, health care providers are required to give patients who do not have insurance, or who are not using insurance, an estimate of expected charges for medical services, including psychotherapy and other mental or behavioral health services.

​

When You Can Expect a Good Faith Estimate

• Scheduled services: If you schedule a health care service at least 3 business days in advance, MYINDSET will provide you with a written Good Faith Estimate within 1 business day after scheduling.

• Services scheduled at least 10 business days in advance: You will receive your Good Faith Estimate within 3 business days after scheduling.

• Upon request: You have the right to request a Good Faith Estimate at any time before receiving a service. To request an estimate, contact our office using the information below.

​

What the Good Faith Estimate Includes

Your Good Faith Estimate will include the expected charges for the primary service you are scheduling, as well as any reasonably expected associated items or services provided by MYINDSET as part of that visit (such as diagnostic assessments or lab work, if applicable). The estimate will include:

• A description of the service(s) to be provided

• The expected date(s) of service

• The expected charge(s) for each service

• The diagnosis code(s), if applicable

• The National Provider Identifier (NPI) and Tax Identification Number (TIN) of MYINDSET

​

Important Information About Good Faith Estimates

• A Good Faith Estimate is not a bill and does not require you to obtain the services listed.

• The actual charges may differ from the estimate if your treatment plan changes, if additional services become clinically necessary, or if unforeseen circumstances arise during treatment.

• A Good Faith Estimate does not include charges from other providers or facilities that may be involved in your care (for example, laboratory services performed by an outside lab).

• Good Faith Estimates apply to uninsured and self-pay patients. If you have insurance and choose not to use it for a particular service, you may request a Good Faith Estimate for that service.

​

Your Right to Dispute a Bill

If you receive a bill that is at least $400 more than your Good Faith Estimate, you may be eligible to dispute the bill through an independent patient-provider dispute resolution process.

To start a dispute, you must initiate the process within 120 calendar days of the date on the bill. There is a $25 administrative fee to initiate the dispute, which may be refunded if the dispute is resolved in your favor.

To learn more about the dispute resolution process or to initiate a dispute, visit:

• CMS No Surprises Help Desk: www.cms.gov/nosurprises

• Phone: 1-800-985-3059

​

​

Questions?

If you have questions about Good Faith Estimates or your rights under the No Surprises Act, please contact our office:

MYINDSET 7230 Arbuckle Commons, Suite 256 Brownsburg, IN 46112 Phone: (317) 207-0273 Email: contact@myindset.com

For more information about your rights under federal law, visit www.cms.gov/nosurprises.