Good Faith Estimate (No Surprises Act Notice)

Who This Applies To

This right applies to any patient who is uninsured or who chooses not to use insurance (self-pay/out-of-network). It does not apply to patients whose visits are being fully or partially covered by an in-network insurance plan.

Your Rights Under the Law

• Advance Estimates: You have the right to receive a written Good Faith Estimate for the total expected cost of non-emergency psychiatric evaluation and treatment services before scheduling.
• The $400 Rule: If you receive a bill from Zeva Care that is at least $400 more than your Good Faith Estimate, you have the legal right to dispute the bill.
• No Obligation: A Good Faith Estimate is for informational purposes. It is not a contract and does not obligate you to obtain services from us.

Our Standard Self-Pay Pricing

For patients who are uninsured or electing not to utilize health insurance, our baseline rates for standard services are:

• Initial Psychiatric Evaluation (CPT 90792): $425 (Approximately 60 minutes via secure telehealth)
• Follow-Up Care / Medication Management: Billed per subsequent session. A personalized, itemized estimate for ongoing care will be provided upon request prior to scheduling.

How to Request an Estimate or Dispute a Bill

• To Request a Personalized GFE: Contact our administration team at hello@zevacare.com or call (267) 996-9382.
• To Dispute a Bill: If your bill exceeds your estimate by $400 or more, you can initiate a dispute process with the U.S. Department of Health and Human Services (HHS) within 120 days of the billing date.

For questions or additional information regarding your right to a Good Faith Estimate, visit cms.gov/nosurprises or call 1-800-985-3059.