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No Suprises Act and Good Faith Estimate Policy

Your Right to a Good Faith Estimate

Under federal law, known as the No Surprises Act, you have the right to receive a Good Faith Estimate of expected charges if you are uninsured or choose not to use your health insurance (self-pay). A Good Faith Estimate explains how much your medical care is expected to cost. This estimate is provided before you receive services and is based on the information known at the time the estimate is created.

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Who Can Receive a Good Faith Estimate

You have the right to receive a Good Faith Estimate if you:

  • Do not have health insurance, or

  • Choose not to use your health insurance for a service

This applies to all services provided by Hope Psychiatry, LLC, including psychiatric evaluations, medication management visits, psychotherapy services when applicable, and related care.

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What the Good Faith Estimate Includes

The Good Faith Estimate will include:

  • A description of the services reasonably expected to be provided

  • The estimated charges for those services

  • Any expected related charges

The estimate is not a contract, and actual charges may vary based on your clinical needs or changes to your care plan.

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Timing of the Estimate

  • If you schedule a service at least 10 business days in advance, you will receive your Good Faith Estimate within 3 business days of scheduling.

  • If you schedule a service at least 3 business days in advance, you will receive your Good Faith Estimate within 1 business day of scheduling.

  • If you request a Good Faith Estimate before scheduling a service, one will be provided within 3 business days of your request.

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Disputing Charges

If you receive a bill that is at least $400 more than your Good Faith Estimate, you may have the right to dispute the charges through a federal Patient-Provider Dispute Resolution (PPDR) process.

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Information about this process is available at:
www.cms.gov/nosurprises

You may also contact the U.S. Department of Health and Human Services at 1-800-985-3059 for assistance.

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Questions or Requests

If you have questions about this policy or would like to request a Good Faith Estimate, please contact:

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Hope Psychiatry, LLC
7201 Metro Blvd, Suite 550
Edina, MN 55439
Phone: 952-520-3649
Email: welcome@hopeinmn.com
Website: www.hopeinmn.com

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Policy Effective Date: January 1, 2026​​

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