GOOD FAITH ESTIMATE NOTICE
Effective Date: August 20, 2026
Last Updated: August 20, 2026
Under the federal No Surprises Act, individuals who do not have health insurance or who choose not to use health insurance to pay for their care generally have the right to receive a Good Faith Estimate explaining the expected cost of scheduled health care services.
This notice explains those rights for self-pay and uninsured patients receiving services through Root & Rise Brain Health.
WHO MAY RECEIVE A GOOD FAITH ESTIMATE
You may be entitled to a Good Faith Estimate if:
You do not have health insurance; or
You have health insurance but choose not to use it to pay for the scheduled service.
A Good Faith Estimate generally does not apply to services that are being billed to and processed through your health insurance plan.
YOUR RIGHT TO AN ESTIMATE
If you schedule a health care service sufficiently in advance, Root & Rise Brain Health will provide a Good Faith Estimate of the expected charges as required by federal law.
You may also request a Good Faith Estimate before scheduling a service.
The estimate will be based on information reasonably known at the time it is prepared.
ROOT & RISE BRAIN HEALTH SELF-PAY FEES
Current self-pay fees are:
Comprehensive Psychiatric Evaluation: $325
Medication Management Follow-Up: $175
Complimentary 15-Minute Consultation: No charge
These fees represent the expected charge for the listed Root & Rise Brain Health service unless you are informed otherwise before receiving care.
WHAT A GOOD FAITH ESTIMATE MEANS
A Good Faith Estimate is an estimate of reasonably expected charges based on the information available when the estimate is prepared.
It is not a contract and does not require you to receive the services listed in the estimate.
The actual services needed may change based on your clinical circumstances.
If additional or different services become necessary, the expected cost may differ from the original estimate.
When reasonably possible, Root & Rise Brain Health will discuss material changes in expected services or charges with you.
RECURRING PSYCHIATRIC CARE
Psychiatric care may involve a series of follow-up appointments rather than a single visit.
When permitted under applicable requirements, a Good Faith Estimate may include expected charges for recurring services during a defined period.
The number and frequency of follow-up appointments depend on your individual clinical needs and cannot always be predicted precisely at the beginning of treatment.
You are not required to continue treatment for the entire period reflected in an estimate.
INSURANCE AND SELF-PAY STATUS
If you intend to use health insurance, your out-of-pocket cost may depend on your specific health plan, deductible, copayment, coinsurance, network status, and coverage requirements.
Insurance benefit information is not a guarantee of payment or coverage.
If you choose to receive a service without submitting it to your health insurance plan, the service may be treated as self-pay when legally and contractually permitted.
You should notify Root & Rise Brain Health or the applicable billing platform if your insurance or payment status changes.
SERVICES FROM OTHER PROVIDERS
A Good Faith Estimate from Root & Rise Brain Health generally reflects charges expected from Root & Rise Brain Health.
You may receive separate charges from other providers or organizations involved in your care, such as laboratories, pharmacies, imaging facilities, hospitals, emergency departments, or other health care professionals.
Those organizations may provide their own estimates when required by law.
UNEXPECTED OR ADDITIONAL SERVICES
A Good Faith Estimate is based on information reasonably known at the time it is created.
Unanticipated clinical circumstances may result in additional or different services that were not included in the original estimate.
The Good Faith Estimate does not include emergency services that could not reasonably have been anticipated before care was provided.
IF YOUR BILL IS SUBSTANTIALLY HIGHER THAN YOUR ESTIMATE
If you receive a bill from a provider or facility that is at least $400 more than that provider's or facility's Good Faith Estimate, you may be eligible to use the federal Patient-Provider Dispute Resolution process.
An independent third party may review the Good Faith Estimate and the billed charges to determine the appropriate amount owed.
Additional requirements and filing deadlines apply to the dispute-resolution process.
More information is available from the Centers for Medicare & Medicaid Services.
KEEP YOUR GOOD FAITH ESTIMATE
You should keep a copy of your Good Faith Estimate.
Compare the estimate with any bill you later receive for the applicable services.
If you believe a bill is incorrect or inconsistent with your estimate, you are encouraged to contact Root & Rise Brain Health before initiating a formal dispute so the charge can be reviewed.
CANCELLATION AND NO-SHOW FEES
Good Faith Estimates address expected charges for health care services.
Separate late-cancellation or no-show fees may apply under the Root & Rise Brain Health Cancellation and No-Show Policy when legally and contractually permitted.
Root & Rise Brain Health currently requires at least 48 hours' notice to cancel or reschedule an appointment.
Appointments cancelled or rescheduled with less than 48 hours' notice may be subject to a $100 late-cancellation fee.
Missed appointments without notice may be subject to a $150 no-show fee.
These fees are generally not billed to insurance.
QUESTIONS OR REQUESTS FOR A GOOD FAITH ESTIMATE
To request a Good Faith Estimate or ask questions about expected charges, contact:
Root & Rise Brain Health
Jill Mobley, PMHNP-BC
Phone: (480) 256-2867
Email: jill@rootandrisebrainhealth.com
Website: rootandrisebrainhealth.com
FEDERAL INFORMATION
For additional information regarding your rights under the No Surprises Act and the Good Faith Estimate requirements, visit the Centers for Medicare & Medicaid Services website or contact the federal No Surprises Help Desk.
No Surprises Help Desk: 1-800-985-3059
Receiving a Good Faith Estimate does not waive any rights or protections available to you under federal or applicable state law.