This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to Tides of Change Wellness at the time of the estimate.
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The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. If you are billed for $400 more, per provider, than this Good Faith Estimate (GFE), you have the right to dispute the bill.

To learn more go to 
www.cms.gov/nosurprises 
or
call CMS at 1-800-985-3059.
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You may also start a dispute resolution process with the U.S. Department of Health and Human Services. If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days of the date on the original bill. There is a $25 fee to use the dispute process.

If the agency reviewing your dispute rules in your favor, you will be obligated to pay the price on this GFE. If the agency rules against you and agrees with the health care provider or facility, you will be obligated to pay the higher amount.
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