Good Faith Estimate
This notice is posted in accordance with federal requirements under the No Surprises Act.
Your Right to a Good Faith Estimate
Under the law, health care providers are required to provide patients who do not have insurance or who are not using insurance with an estimate of the expected charges for medical items and services.
You have the right to receive a Good Faith Estimate explaining the expected cost of your medical care, including related costs such as medical tests, prescription medications, equipment, and hospital fees.
- You may request a Good Faith Estimate before scheduling a service or at any time before treatment.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you may dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
- Actual charges may differ if additional services are needed during treatment.
Self-Pay / Out-of-Pocket Fees
Office Visits
- New Patient Visit with QbTest: $572.00 maximum out-of-pocket expense
- Existing Patient Visit with QbTest: $487.00 maximum out-of-pocket expense
- Existing Patient Visit: $265.00 maximum out-of-pocket expense
- ADHD diagnosis letter: No charge
- IEP/504, college, or workplace accommodation forms: $50.00
- Medical records: $1.00/page up to 25 pages; $0.50/page thereafter
- Returned check fee: $35.00
- No-show/late cancellation (<24 hrs) New Patient: $100.00
- No-show/late cancellation (<24 hrs) Existing Patient: $50.00
Important Information About QbTest
QbTest is an important part of our evaluation and treatment process. Unless otherwise noted, patients are responsible for the $200.00 QbTest fee, which is included in the maximum out-of-pocket estimates listed above.
Certain behavioral rating scales may also be considered out-of-network behavioral health services with a maximum additional charge of $21.00.