accepted insurances:

Your Right to a Good Faith Estimate

Under federal law (the No Surprises Act), you have the right to receive a Good Faith Estimate

(GFE) explaining the expected cost of your health care services. This applies to individuals who do not have health insurance or who choose not to use their insurance and instead pay out of pocket (self-pay). A Good Faith Estimate outlines the expected total cost of non-emergency health care services based on the information available at the time the estimate is prepared.

Requesting a Good Faith Estimate

You may request a Good Faith Estimate before scheduling a service, when scheduling a service,

or at any time prior to receiving services.

What to Expect From a Good Faith Estimate

At InnerSpace Center for Emotional Health, therapy is individualized. The frequency, duration, and type of services are determined collaboratively between you and your clinician and may be

influenced by treatment goals, type of therapy, symptom severity, provider availability, scheduling needs, and financial considerations. A Good Faith Estimate reflects the services anticipated at the time it is created and is not a contract or guarantee of final costs. Changes to your treatment plan or additional services may result in charges that differ from the estimate.

Self-Pay Rates

Psychotherapy Services: $80 per session (flat rate). Sessions are typically scheduled for

approximately 45–60 minutes and may include individual or family psychotherapy.

Certified Peer Recovery Specialist (CPRS) Services: $38 per session. Sessions are defined as up

to 60 minutes in duration.

Services Not Included

A Good Faith Estimate includes only the services listed at the time it is prepared. Additional

services such as additional sessions, assessments, documentation requests, letters, reports, or

other clinical services are not included unless explicitly stated and may result in additional

charges.

If You Receive a Bill That Is Higher Than Your Estimate

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

dispute the bill. You may first contact the health care provider or facility listed on your bill to let

them know the billed charges are higher than your Good Faith Estimate. You may ask the provider to update the bill to match the Good Faith Estimate, negotiate the bill, or provide information about available financial assistance. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the federal dispute resolution process, you must start the dispute within 120 calendar days (approximately four months) of the date on the original bill. There is a $25 administrative fee to initiate the dispute. If the reviewing agency agrees with you, you will be required to pay the amount listed on your Good Faith Estimate. If the agency agrees with the provider or facility, you may be required to pay the higher billed amount. To learn more about the dispute resolution process or to begin a dispute, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059. You are encouraged to save a copy or take a picture of your Good Faith Estimate for your records

Contact Information

InnerSpace Center for Emotional Health

Phone: 812-413-0315

Indiana Consumer Notice

This notice is provided in accordance with applicable federal law and Indiana consumer protection standards. Nothing in this notice limits your rights under Indiana law or applicable professional licensing standards governing mental health providers.