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Example

No Surprises Act & Good Faith Estimate Notice

Private Pay Practice Notice

Empower Speech Therapy is a private pay (self-pay) speech-language pathology practice. We do not bill insurance directly. However, under federal law, you still have important rights regarding the cost of your care.

Your Right to a Good Faith Estimate

Under the No Surprises Act, you have the right to receive a Good Faith Estimate of the expected cost of your services.

Because we are a private pay practice, this applies to all clients receiving services with us.

What Is a Good Faith Estimate?

A Good Faith Estimate is a written document that outlines the expected costs of your speech-language pathology services.

This may include:

  • Initial evaluation
  • Ongoing therapy sessions
  • Recommended frequency and duration of care

The estimate reflects the information available at the time and is designed to help you plan financially for your care.

When You Will Receive Your Estimate

You may request a Good Faith Estimate at any time, including:

  • Before scheduling services
  • At the time of scheduling
  • During the course of treatment

We will provide your estimate within the timeframes required by federal law.

If Your Costs Change

Your therapy needs may evolve over time. If your treatment plan changes, we will provide an updated Good Faith Estimate upon request.

What If You Are Billed More Than Expected?

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the charges.

You can begin a dispute resolution process through the U.S. Department of Health and Human Services (HHS).

How to Request a Good Faith Estimate

To request your Good Faith Estimate, please contact us:

  • Phone: 716-201-0453
  • Email: contact@empowerwny.com

Please include:

  • The services you are interested in (evaluation, therapy, etc.)
  • Any scheduling details you may have

Important Notes About Private Pay Services

  • Payment is due at the time services are provided unless otherwise arranged
  • We do not submit claims to insurance
  • Upon request, we can provide documentation (such as a superbill) for you to submit to your insurance for possible out-of-network reimbursement

New York State Protections

New York State also provides protections against surprise medical bills. These protections may complement your rights under federal law.

Accessibility and Language Assistance

We are committed to making this information accessible to all clients.
If you need this notice in another format or language, please contact us.

Questions?

If you have any questions about your Good Faith Estimate or the cost of services, please reach out. We are happy to help you make informed decisions about your care.