Good Faith Estimate Notice
A 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 us when the estimate was conducted.
Important Note: 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.
Contact Us
You may contact your provider’s office at info@releaserenewmentalwellness or 410-376-8728 to inform us if the billed charges are at least $400 higher than the GFE. You can:
- Ask us to update the bill to match the GFE.
- Ask to negotiate the bill.
- Ask if financial assistance is available.
Dispute Resolution Process
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS).
If you choose to use the dispute resolution process, you must start it within 120 calendar days (about 4 months) of the date on the original bill.
- Fee: There is a $25 fee to use the dispute process.
- Outcome: If the reviewing agency agrees with you, you will only have to pay the amount on this GFE. If the agency agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to:
www.cms.gov/nosurprises or call CMS at 1-800-985-3059.
Additional Information
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059.
Note: This GFE is not a contract. It does not obligate you to accept the services listed above.
Storage Recommendation: Keep a copy of this Good Faith Estimate (GFE) in a safe place or take pictures of it. You may need it if you are billed more than $400 over the estimate provided above.