- You have the right to know the expected cost of your care in advance
- This is required by the No Surprises Act for uninsured or self-pay patients
- If your bill is $400+ more than the estimate, you can dispute it
- Ask us for a Good Faith Estimate before scheduling
Read the full document
Good Faith Estimate Notice
Your Right to a Good Faith Estimate Under the No Surprises Act
What is a Good Faith Estimate?
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or who are not seeking to file a claim with their plan or coverage, both orally and in writing, of their ability to receive a Good Faith Estimate of expected charges.
Your Rights
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency health care service, including psychotherapy and psychiatric services.
- You can ask your health care provider for a Good Faith Estimate before you schedule a service
- 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
Estimated Costs at Top Tier Psychiatry
The following are standard self-pay (uninsured) rates for common services. These are estimates and actual charges may vary based on the services provided during your visit:
| Service | Estimated Cost |
|---|---|
| Initial psychiatric evaluation (60 min) | $350 |
| Follow-up medication management (20-30 min) | $160 |
Additional charges that may apply: late cancellation fee ($50), no-show fee ($100).
For Questions or to Request an Estimate
Contact Top Tier Psychiatry at info@toptierpsych.com or (725) 272-2411 to request a personalized Good Faith Estimate before scheduling your appointment.
Dispute Resolution
If you are billed for more than the Good Faith Estimate (at least $400 more), you may be eligible to start a patient-provider dispute resolution process. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit cms.gov/nosurprises or call 1-800-985-3059.