Good Faith Estimate Notice
Sophia Haeri, Ph.D.
Bellewood Psychology PLLC
Effective date: November 1, 2026
You have the right to an estimate of expected health care charges
If you do not have health insurance or are choosing not to use insurance to pay for your care, you generally have the right under federal law to receive a written Good Faith Estimate of expected charges for nonemergency health care services.
A Good Faith Estimate explains the services reasonably expected to be provided and their expected charges. It is an estimate, not a bill or a requirement to receive services. It does not guarantee an insurance benefit or reimbursement.
When an estimate is provided
You may request an estimate before deciding whether to schedule care. An estimate is generally required when care is scheduled at least three business days in advance. When scheduled three to nine business days ahead, it is generally due within one business day of scheduling; when scheduled ten or more business days ahead, it is generally due within three business days. An estimate requested before scheduling is generally due within three business days of the request.
For ongoing therapy, an estimate can describe anticipated services and charges over a stated period. Your actual treatment needs and frequency may change. Ask for an explanation or updated estimate when the expected services or charges change.
If your bill is higher than the estimate
If a bill from a provider is at least $400 higher than that provider's Good Faith Estimate, you may qualify for the federal patient-provider dispute resolution process. You generally must start the dispute within 120 calendar days of the date on the initial bill. Keep a copy of your estimate and bills. Visit https://www.cms.gov/nosurprises for current information about eligibility, procedures, and any administrative fee.
How to request an estimate
Contact Dr. Sophia Haeri at Bellewood Psychology PLLC:
Email: drsophiahaeri@bellewoodpsychology.com
Phone: (917) 525-3929
Mailing address: 145 Palisade St, Suite 216, Dobbs Ferry, NY 10522
Please avoid including detailed health information in ordinary email. A secure method can be arranged if needed. This public notice explains your rights; your individualized Good Faith Estimate will identify the services and charges expected for your care.