No Surprises Act — Good Faith Estimate Notice

Effective Date: June 18, 2026

Your Right to a Good Faith Estimate

Under the No Surprises Act (effective January 1, 2022), you have the right to receive a Good Faith Estimate for the expected cost of any non-emergency healthcare items or services provided by Dallas Psychiatry Group.

What Is a Good Faith Estimate? A Good Faith Estimate is a written estimate of the expected charges for your healthcare services. It is provided before your scheduled service or upon request, and helps you understand and plan for the cost of your care.

Who Is Eligible? You have the right to receive a Good Faith Estimate if you:

  • Do not have health insurance, OR

  • Have health insurance but choose not to use it for the services you are scheduling (self-pay)

What Does It Include? Your Good Faith Estimate will include the expected cost of:

  • Psychiatric evaluations and consultations

  • Psychotherapy sessions

  • Medication management visits

  • Any other items or services associated with your care at this practice

The estimate reflects the expected charges from Dallas Psychiatry Group only and may not include costs from other providers (e.g., labs, specialists, hospitals) that may be involved in your care.

How to Request a Good Faith Estimate You may request a Good Faith Estimate at any time before your scheduled service. To request one, contact us at:

Dallas Psychiatry Group Email: info@dallaspsychiatrygroup.com Phone: (469) 246-2333

We will provide your Good Faith Estimate within:

  • 1 business day if your service is scheduled within 3 days

  • 3 business days if your service is scheduled at least 10 days in advance

  • Within 3 business days of your request if no appointment is scheduled

What If My Bill Is Higher Than the Estimate? If your actual bill is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill. To initiate a dispute, you must contact us within 120 calendar days of the date on your bill.

For information about the dispute resolution process or more information about your rights under the No Surprises Act, visit: cms.gov/nosurprises