Your Right to a Good Faith Estimate
Clarivolve Mental Health
Effective Date: October 10, 2026
Know Your Healthcare Costs Before Your Appointment
Under the federal No Surprises Act, patients who do not have health insurance or who choose not to use their insurance generally have the right to receive a Good Faith Estimate of expected healthcare charges.
A Good Faith Estimate explains the expected cost of scheduled services before care is provided.
Self-Pay Rates
ServicePriceInitial Psychiatric Evaluation$250Follow-Up Medication Management$100Comprehensive ADHD Evaluation, including QbCheck$550Standalone QbCheck Testing$199
The comprehensive ADHD evaluation includes the initial psychiatric evaluation, QbCheck computerized testing, and clinical interpretation of results.
These are published self-pay rates. Your individualized Good Faith Estimate will reflect the services reasonably expected for your scheduled care.
When You Can Receive an Estimate
If you are uninsured or are not using insurance:
If you schedule at least 3 business days in advance, you generally must receive an estimate within 1 business day after scheduling.
If you schedule at least 10 business days in advance, you generally must receive an estimate within 3 business days after scheduling.
If you request an estimate before scheduling, you generally must receive it within 3 business days.
You may request a Good Faith Estimate before booking an appointment.
What Your Estimate Includes
Your written Good Faith Estimate will identify the reasonably expected charges for scheduled healthcare services, including applicable items and services anticipated as part of your care.
The estimate is not a bill. Actual charges may differ if your care needs change or additional services become necessary.
Your Right to Dispute a Bill
If your final bill from a provider is at least $400 more than the Good Faith Estimate from that provider, you may qualify for the federal patient-provider dispute resolution process.
You generally must begin the dispute process within 120 calendar days of the initial bill.
For more information, visit:
https://www.cms.gov/medical-bill-rights
You may also contact the No Surprises Help Desk at 1-800-985-3059.
Request a Good Faith Estimate
Clarivolve Mental Health
104 E Olive Ave, Suite #100
Redlands, CA
Phone: (951) 517-3701
Email: anikpour@clarivolve.com
Please contact our office to request a written Good Faith Estimate or discuss expected self-pay charges.