Good Faith Estimate
Good Faith Estimate Your Right to Receive an Estimate of Expected Charges
Under federal law, individuals who do not have health insurance or who are not using insurance to pay for a health care service generally have the right to receive a Good Faith Estimate explaining the expected cost of that service.
Tosa Psychological Services, LLC is a private-pay and out-of-network psychology practice. If you are uninsured or will not be using insurance for a service, you may be entitled to a written Good Faith Estimate of the charges you can reasonably expect.
When You Will Receive a Good Faith Estimate
If you schedule a qualifying service:
- 3 to 9 business days in advance: Your Good Faith Estimate will generally be provided within 1 business day after scheduling.
- 10 or more business days in advance: Your Good Faith Estimate will generally be provided within 3 business days after scheduling.
- If you request an estimate before scheduling: Your Good Faith Estimate will generally be provided within 3 business days after your request.
You may request a Good Faith Estimate even if you have not yet scheduled an appointment.
What the Estimate Includes
Your Good Faith Estimate will identify the expected charges for the items or services reasonably expected to be provided by Tosa Psychological Services.
For ongoing services, such as psychotherapy, the estimate may reflect an anticipated frequency and course of treatment. Actual treatment needs may change over time. If the expected scope or frequency of services changes materially, an updated estimate may be provided.
A Good Faith Estimate is an estimate of expected charges and is not a guarantee of the exact final amount you will be charged.
If Your Bill Is Substantially Higher Than Your Estimate
If the amount billed by a provider is $400 or more above the amount listed for that provider on your Good Faith Estimate, you may be eligible to use the federal patient-provider dispute resolution process.
You should keep a copy of your Good Faith Estimate and compare it with any bills you receive.
Additional information about Good Faith Estimates and the federal dispute-resolution process is available from the Centers for Medicare & Medicaid Services.
Requesting a Good Faith Estimate
To request a Good Faith Estimate or ask questions about the expected cost of services, please contact:
Tosa Psychological Services, LLC
9205 W Center Street, Suite 203
Milwaukee, WI 53222
Phone: (414) 377-4787
Email: connect@tosapsych.com
You may also ask about expected charges when contacting us to schedule services.