Good Faith Estimate


Transformations seeks to comply with the No Surprises Act, title 45, section 149.610 of the Code of Federal Regulations enacted with the primary goal of protecting clients from unexpected medical bills. 


All Clients will be asked to submit a request for services through the website and to indicate any insurance coverage.

Fees and description of services will be posted on the website for client access.

Clients (uninsured or seif-pay) who request to pay directly for the services they receive will be offered a Diagnostic Evaluation Session (90791) resulting in a diagnosis and treatment plan recommendations.  The plan will include recommended services with the CPT service code and agency fee, the frequency and intensity of services, and target date for goal attainment.  The plan shall include a good faith estimate for the cost of services for the treatment period for up to one year.  Any changes in the plan shall result in a new updated good faith estimate. If services exceed one year, a new estimate shall be provided to the client.

Applicable clients will be asked to sign the good faith estimate as proof of receipt and acceptance of the plan.  Their signature is not a commitment to complete the recommended treatment regime.

The good faith estimate shall be written in a clear and understandable manner.  The plan maybe read to clients at their request and in their preferred language.

The good faith estimate shall be provided within the following time frames:  If the session is scheduled three days out the provider must give the client a Good Faith Estimate no later than one (1) business day after the day that the provider and client arrange an appointment.  If the appointment is scheduled 10 days out, the provider must provide the Good Faith Estimate within 3 business days.  And if the uninsured self-pay client asks for a good faith estimate, the provider has 3 business days to provide the document to the client.

A good faith estimate shall include the following:

  • client’s name and date of birth,
  • diagnosis code and description,
  • CPT code and description of service,
  • fees for each type of service, 
  • estimated frequency of service,
  • Estimated target date for end of services (no more than 12 months),
  • Provider Name
  • Provider NPI number
  • Transformations tax identification number,
  • Office or location where services are expected to be provided,
  • Disclaimers describing the legal limits of the good faith estimate.

A food faith estimate shall be considered part of the client’s medical record and stored in the agency electronic medical records system.  Transformations shall consider a good faith estimate as protected healthcare information.

If the agency or provider makes an error in the Good Faith Estimate a correction shall be made at the time of the discovery and submitted to the client.  If services were already furnished prior to the correction of the error, the provider or agency maybe subject to dispute resolution if the actual billed charges are substantially in excess of the estimate.

The good faith estimate shall include the following disclaimers:

  • There may be additional service recommendations as part of the treatment process that will be scheduled or requested separately and are not reflected in the good faith estimate.
  • The information provided in the good faith estimate is only an estimate regarding services reasonably expected to be furnished at the time of the estimate and actual services or charges may differ from the good faith estimate.
  • The client has the right to dispute the charges if they are substantially in excess of the expected charges.  To dispute charges, send an email to or by mail to 4010 Dupont Circle # 582 Louisville KY 40207.  If you are not satisfied with the resolution, contact Teri Lloyd, CEO at
  • The good faith estimate is not a contract and does not require the uninsured individual to obtain any of the services identified in the good faith estimate.  


Good Faith Estimate Form

Federal Regulation 149.610 Requirements for provision of good faith estimates of expedited charges for uninsured (or self-pay) individuals.

Effective 1-1-2022