Federal Disclosure

Your Rights Under the No Surprises Act

Effective date: May 6, 2026 · Last updated: May 6, 2026

1. Required CMS Notice — Right to Receive a Good Faith Estimate

You have the right to receive a "Good Faith Estimate" explaining how much your medical and mental health care will cost.

Under the law, health care providers need to give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • 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 medical tests, prescription drugs, equipment, and hospital fees.
  • 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 your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • 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.

2. Who This Applies To

This notice and the Good Faith Estimate process apply to clients of Pasadena Clinical Group who are uninsured or who are not planning to submit a claim to their health plan for the services we provide ("self-pay"). It is required by Section 2799B-6 of the Public Health Service Act, as amended by the No Surprises Act, and the implementing regulations at 45 C.F.R. §149.610.

3. When You Will Receive Your Estimate

  1. If you schedule an item or service at least 10 business days in advance, you will receive your Good Faith Estimate within three (3) business days of scheduling.
  2. If you schedule an item or service at least 3, but fewer than 10, business days in advance, you will receive your Good Faith Estimate within one (1) business day of scheduling.
  3. If you request a Good Faith Estimate without scheduling, you will receive one within three (3) business days of the request.

If we expect any change to the items, services, or charges before your appointment, we will issue a new Good Faith Estimate within one (1) business day before the appointment. We will provide the estimate in writing through the patient portal or by mail at your request, and we will discuss it with you in plain language.

4. What Is in a Good Faith Estimate

Each Good Faith Estimate will include, at minimum, the items required by 45 C.F.R. §149.610(c)(1):

  • Your name and date of birth.
  • A description of the primary item or service (for example, "individual outpatient psychotherapy, 60 minutes").
  • The expected service codes (CPT) and any modifiers, the diagnosis code (ICD-10), and the expected charge for each item or service.
  • The expected number of sessions, if known. If you continue treatment beyond the period covered by your initial estimate, we will issue a new estimate.
  • The name, National Provider Identifier (NPI), and Tax Identification Number (TIN) of the rendering provider, and the location where the services are expected to be furnished.
  • A list of items or services that the provider anticipates will require separate scheduling and that are expected to occur before or following the primary item or service.
  • A disclaimer that the Good Faith Estimate is only an estimate, that actual items, services, or charges may differ, and that you have the right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges in the estimate.
  • A disclaimer that the Good Faith Estimate is not a contract and does not require you to obtain the items or services from Pasadena Clinical Group.

5. The Patient-Provider Dispute Resolution Process

If you receive a bill that is at least $400 more than the expected charges listed in your Good Faith Estimate for any item or service from the same provider, you may initiate a Patient-Provider Dispute Resolution (PPDR) process administered by the U.S. Department of Health and Human Services. Key features of that process:

  • You must initiate PPDR within 120 calendar days of receiving the original bill.
  • An administrative fee applies, which may be waived for low-income clients.
  • While the dispute is pending, the provider is generally prohibited from sending the bill to collections, accruing additional late fees, or threatening or taking retaliatory action against you.
  • The Selected Dispute Resolution (SDR) entity will determine the appropriate amount.

Information and the dispute initiation form are available at www.cms.gov/nosurprises.

6. California-Specific Notes

Most clients of Pasadena Clinical Group who use commercial health insurance are not at risk of out-of-network "surprise billing" for outpatient psychotherapy. California's Health Care Service Plan Knox-Keene Act (Health & Safety Code §1371.9) and Insurance Code §1371.9 generally limit non-contracting individual health professionals at in-network facilities to in-network cost-sharing. We document our network status with each plan during benefits verification.

7. Receipt and Acknowledgment

Where required by 45 C.F.R. §149.610(b)(1)(iv), we will document that you have received this notice. You may request a copy at any time.

8. Disputes Outside the Federal NSA Process

The federal Patient-Provider Dispute Resolution process described in Section 5 above is the exclusive process for billing disputes that fall within its scope. Disputes that fall outside the federal NSA process — including disputes about clinical care, professional negligence, the patient relationship, or non-NSA billing matters — are governed by the Mediation, Then Binding Arbitration Agreement in Sections 15–18 of the Treatment Consent (including the bold-face notice and 30-day right of rescission required by California Code of Civil Procedure §1295) and, where applicable, by the dispute-resolution provisions of our Terms and Conditions. Nothing in this Notice limits your right to file a complaint with the U.S. Department of Health and Human Services, the California Department of Managed Health Care, the California Department of Insurance, or any other government agency.

Contact

Questions about a Good Faith Estimate from Pasadena Clinical Group:
Pasadena Clinical Group, 301 N. Lake Ave, STE 600, Pasadena, CA 91101
(626) 354-6440 · office@pasadenaclinicalgroup.com