⚠Template content — must be reviewed and finalized by the practice’s California-licensed attorney and compliance officer before publication.
Effective Date: April 29, 2026 · Last Updated: April 29, 2026
Questions or notices:
office@pasadenaclinicalgroup.com · 301 N. Lake Ave, STE 600, Pasadena, CA 91101 · (626) 354-6440
Your right to a Good Faith Estimate
Under the federal No Surprises Act, you have the right to receive a Good Faith Estimate (GFE) of expected charges for medical items and services, including psychotherapy.
What this means
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like psychological testing, group sessions, or ongoing care.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask for one before scheduling.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.
Dispute resolution
If your bill is at least $400 more than your Good Faith Estimate, you may initiate the patient-provider dispute resolution process at www.cms.gov/nosurprises within 120 days of receiving the bill.
How to request a Good Faith Estimate from us
Email office@pasadenaclinicalgroup.com or call (626) 354-6440. We will provide your written Good Faith Estimate within the timeframes required by 45 CFR 149.610.
Statutory and regulatory framework
- No Surprises Act — Pub. L. 116-260, Division BB (Title I), and implementing regulations at 45 CFR § 149.610 (Good Faith Estimates) and 45 CFR Part 149 generally (surprise medical billing protections).
- Patient-Provider Dispute Resolution — 45 CFR § 149.620 (federal SDR process for uninsured / self-pay billing disputes).
- California AB 72 / Cal. Health & Safety Code § 1371.30 — California state-law surprise-billing protections for in-network plans.
- California Knox-Keene Act — Cal. Health & Safety Code § 1340 et seq.
- Mental Health Parity and Addiction Equity Act ("MHPAEA") — 29 U.S.C. § 1185a; 42 U.S.C. § 300gg-26; 45 CFR § 146.136.
This notice contains the standard CMS disclosure language required by 45 CFR § 149.610 regarding your right to a Good Faith Estimate. Where federal and California law differ, the protection more favorable to you applies.