top of page

No Surprises Act & Good Faith Estimate Disclosure Statement

Roiya Center for Experiential Healing

Effective Date: August 1st, 2025

​

Your Right to a Good Faith Estimate

You have the right to receive a Good Faith Estimate (GFE) explaining how much your mental health care will cost.

 

Under the No Surprises Act (Section 2799B-6 of the Public Health Service Act), all health care providers—including mental health professionals—are required to give clients who do not have insurance or who are not using insurance an estimate of expected charges before services are provided.

​

When You Will Receive a Good Faith Estimate

  • You will receive a written GFE at least one business day before your first scheduled session, if the appointment is scheduled three or more business days in advance.

  • If you request a GFE before scheduling, Roiya will provide it within three business days of your request.

  • You may also receive an updated GFE if your treatment plan changes.

​​​

What the Good Faith Estimate Includes

The GFE will outline:

  • The estimated cost of each session or service (based on session length and clinician level);

  • The expected number of sessions, if known;

  • Any other costs reasonably expected (such as late-cancellation fees or documentation requests); and

  • The total estimated charges for your anticipated course of care.

Your GFE is not a contract or bill. Actual costs may vary based on your individual treatment needs and progress.

​

Keep a Copy

Please keep a copy or picture of your Good Faith Estimate for your records. It may be helpful if you receive a bill that differs from the estimate.

​

If Your Bill 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 can start a dispute resolution process with the U.S. Department of Health and Human Services (HHS) within 120 days of receiving the bill.

 

You must include a copy of your bill and your Good Faith Estimate. There is a $25 administrative fee to start the process.

​

Questions or Assistance

If you have any questions about your Good Faith Estimate or your rights under the No Surprises Act, please contact:

Roiya Center for Experiential Healing
📍 830 Stewart Dr, Ste 115, Sunnyvale, CA, 94085
📞 669-256-1112
📧 support@roiyacenter.com
🌐 www.roiyacenter.com

​

This notice is provided in compliance with federal law (45 CFR §149.610) and applies to all clients who are self-pay, uninsured, or elect not to use insurance benefits. Roiya Center for Experiential Healing is an outpatient mental health practice; emergency and hospital-based provisions of the No Surprises Act do not apply to our services.

bottom of page