Change in Entropy Hypnotherapy
Website: https://www.change-in-entropy.com/
Effective Date: March 17, 2026
Last Updated: March 17, 2026

Contact Information
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: [email protected]
Phone: (907) 278-1180

Your Right to Receive a Good Faith Estimate

Under federal law, health care providers must give uninsured or self-pay individuals a Good Faith Estimate of expected charges for scheduled items and services in certain situations. A self-pay individual is someone who has insurance but chooses not to use it for a particular item or service.

You have the right to receive a Good Faith Estimate for the total expected cost of non-emergency services provided by Change in Entropy Hypnotherapy when required by law.

When you should receive it

If you schedule a service at least 3 business days in advance, you should receive a written Good Faith Estimate. If you schedule a service 3 to 9 business days in advance, the estimate must generally be given within 1 business day after scheduling. If you schedule a service 10 or more business days in advance, the estimate must generally be given within 3 business days after scheduling. If you ask for a Good Faith Estimate before scheduling, it must generally be provided within 3 business days after your request.

What it includes

A Good Faith Estimate describes the expected charges for the scheduled health care items or services from this provider. Good Faith Estimates generally list expected charges for a single provider or facility.

Keep a copy

You should keep a copy or photo of your Good Faith Estimate. You may need it if you are billed more than expected.

If your bill is much higher than your estimate

If you receive a bill from this provider that is at least $400 more than your Good Faith Estimate from this provider, you may have the right to start a Patient-Provider Dispute Resolution process.

For questions or more information about your right to a Good Faith Estimate, visit the federal medical bill rights site or call 1-800-985-3059. CMS also lists [email protected] for questions about the federal process.

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2) Good Faith Estimate and Patient-Provider Dispute Notice

Change in Entropy Hypnotherapy
Website: https://www.change-in-entropy.com/
Effective Date: March 17, 2026
Last Updated: March 17, 2026

Provider Contact Information
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: [email protected]
Phone: (907) 278-1180

Good Faith Estimate for Health Care Items and Services

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service scheduled with Change in Entropy Hypnotherapy. The estimate is based on information known at the time it is prepared. Actual charges may differ if additional or unexpected services are needed. CMS explains that a Good Faith Estimate is an estimate, not a bill, and may not include unanticipated services.

Patient Information

Patient Full Name: ______________________________________

Date of Birth: __________________________________________

Mailing Address: ________________________________________

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Phone: ________________________________________________

Email: ________________________________________________

Estimate Details

Date Estimate Provided: _________________________________

Method Provided:
☐ Paper
☐ Email
☐ Portal
☐ Other: ______________________________________

Scheduled Service Date: _________________________________

Scheduled Time: ________________________________________

Provider: Change in Entropy Hypnotherapy

Provider Address:
2862 Change Street, Unit A
Los Alamos, NM 87544

Provider Phone: (907) 278-1180

Provider Email: [email protected]

Patient Status

☐ Uninsured
☐ Self-pay, choosing not to use insurance for this service

Description of Expected Items and Services

Estimated Total Expected Charges: $________________

Notes About This Estimate

This Good Faith Estimate includes only the expected charges for services provided by Change in Entropy Hypnotherapy. If you receive other services from another provider or facility, you may receive separate estimates from them. CMS states that Good Faith Estimates generally list expected charges for a single provider or facility.

This estimate is not a contract and does not require you to obtain services. Actual charges may be different if your care needs change or if additional items or services are reasonably necessary.

Patient-Provider Dispute Resolution Notice

If you are billed $400 or more above this Good Faith Estimate from this provider, you may have the right to dispute the bill through the federal Patient-Provider Dispute Resolution process.

To start that process, the patient or an authorized representative may submit a request through the federal process and pay the applicable administrative fee required by the government at that time. An independent third party will review the estimate, the bill, and supporting information and determine the appropriate payment amount.

For questions about your rights or the dispute process, contact:

CMS / Federal No Surprises Help
Phone: 1-800-985-3059
Email: [email protected]

Important Patient Information

Keep a copy or photo of this form for your records.

This form is an estimate only. It is not a bill.

Patient Acknowledgment of Receipt

I acknowledge that I received this Good Faith Estimate.

Patient Signature: ______________________________________

Date: _________________________________________________

Personal Representative, if applicable

Name: _________________________________________________

Relationship to Patient: __________________________________

Signature: _____________________________________________

Date: _________________________________________________

Practice Use Only

Prepared By: ___________________________________________

Date: _________________________________________________

Revision / Update Issued On: _____________________________