Patient rights · No Surprises Act

Good Faith Estimate

Last updated: May 2026

Under the federal No Surprises Act, patients who are uninsured or who choose not to use insurance ("self-pay" patients) have the right to receive a "Good Faith Estimate" of expected charges for medical services, including psychiatric care.

What a Good Faith Estimate includes

A Good Faith Estimate shows the costs of items and services reasonably expected for your health care needs. The estimate is based on information known at the time it is created and may include:

  • Initial evaluation fees
  • Typical follow-up appointment fees
  • Anticipated frequency of visits
  • Any other services reasonably expected as part of your care

The estimate is not a contract and does not obligate you to receive the services listed. Actual charges may differ if your care needs change.

Your right to receive an estimate

You have the right to:

  • Receive a Good Faith Estimate in writing at least one business day before a medical service or item, or upon request before scheduling.
  • Ask any health care provider or facility for a Good Faith Estimate before you schedule a service.
  • Save a copy of your Good Faith Estimate for your records.

How to request your estimate

To request a Good Faith Estimate for psychiatric services from Bella Acosta Arias, MD, PLLC, contact the practice at hello@bellaacostamd.com. You will receive a written estimate within the timeframes required by federal regulation.

Estimates for forensic engagements are provided directly to retaining counsel as part of the engagement letter process and are not subject to the No Surprises Act in the same manner as patient care.

Your right to dispute a bill

If you receive a bill from a provider that is at least $400 more than your Good Faith Estimate for that provider, you may dispute the bill through the federal patient–provider dispute resolution process. You have 120 calendar days from the date on the original bill to initiate the dispute process.

For more information, including how to start a dispute, visit cms.gov/nosurprises or call 1-800-985-3059.

Keep your estimate

Save a copy of your Good Faith Estimate in a safe place. You may need it if you are billed a higher amount than what is listed in the estimate.

Questions

Questions about the No Surprises Act or your Good Faith Estimate from this practice can be directed to hello@bellaacostamd.com.

This page summarizes federal Good Faith Estimate requirements for informational purposes. It is not legal advice. Practices are responsible for providing the formal estimate in the format and timing required by CMS.