Call today for a FREE consultation! (716) 201-0453

Example

No Surprises Act & Good Faith Estimate Notice

Private Pay Practice Notice

Empower Speech Therapy operates as a private pay (self-pay) speech-language pathology practice that doesn't bill insurance directly, though federal law grants you rights regarding care costs.

Your Right to a Good Faith Estimate

Under the No Surprises Act, clients have the right to receive a written Good Faith Estimate outlining expected service costs before treatment begins.

What Is a Good Faith Estimate?

A Good Faith Estimate documents anticipated expenses, potentially covering:

  • Initial evaluation
  • Ongoing therapy sessions
  • Recommended treatment frequency and duration

The estimate reflects available information at the time of request.

When You Will Receive Your Estimate

Estimates can be requested:

  • Before scheduling
  • At scheduling time
  • During active treatment

The practice provides estimates within federally required timeframes.

If Your Costs Change

Treatment plans may evolve. Updated estimates are provided upon request if your therapy needs shift.

What If You Are Billed More Than Expected?

Bills exceeding your estimate by at least $400 more qualify for dispute resolution through the U.S. Department of Health and Human Services.

How to Request a Good Faith Estimate

Contact information:

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

Include services desired and scheduling details.

Important Notes About Private Pay Services

  • Payment required at service delivery unless arranged otherwise
  • No insurance claim submissions
  • Superbills available for out-of-network reimbursement requests

New York State Protections

State-level protections complement federal safeguards against surprise bills.

Accessibility and Language Assistance

Alternative formats and languages available upon request.