{"id":299,"date":"2026-03-17T15:01:57","date_gmt":"2026-03-17T15:01:57","guid":{"rendered":"https:\/\/www.change-in-entropy.com\/?page_id=299"},"modified":"2026-03-17T15:02:39","modified_gmt":"2026-03-17T15:02:39","slug":"notice-of-right-to-receive-a-good-faith-estimate","status":"publish","type":"page","link":"https:\/\/www.change-in-entropy.com\/index.php\/notice-of-right-to-receive-a-good-faith-estimate\/","title":{"rendered":"Notice of Right to Receive a Good Faith Estimate"},"content":{"rendered":"\t\t
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Change in Entropy Hypnotherapy<\/strong>
Website:<\/strong> https:\/\/www.change-in-entropy.com\/<\/a>
Effective Date:<\/strong> March 17, 2026
Last Updated:<\/strong> March 17, 2026<\/p>

Contact Information<\/strong>
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: jennifer@change-in-entropy.com<\/a>
Phone: (907) 278-1180<\/p>

Your Right to Receive a Good Faith Estimate<\/h2>

Under federal law, health care providers must give uninsured or self-pay individuals a Good Faith Estimate<\/strong> 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.<\/p>

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.<\/p>

When you should receive it<\/h3>

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

What it includes<\/h3>

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<\/strong>.<\/p>

Keep a copy<\/h3>

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

If your bill is much higher than your estimate<\/h3>

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

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<\/strong>. CMS also lists FederalPPDRQuestions@cms.hhs.gov<\/a><\/strong> for questions about the federal process.<\/p>

2) Good Faith Estimate and Patient-Provider Dispute Notice<\/h1>

Change in Entropy Hypnotherapy<\/strong>
Website:<\/strong> https:\/\/www.change-in-entropy.com\/<\/a>
Effective Date:<\/strong> March 17, 2026
Last Updated:<\/strong> March 17, 2026<\/p>

Provider Contact Information<\/strong>
Change in Entropy Hypnotherapy
2862 Change Street, Unit A
Los Alamos, NM 87544
Email: jennifer@change-in-entropy.com<\/a>
Phone: (907) 278-1180<\/p>

Good Faith Estimate for Health Care Items and Services<\/h2>

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.<\/p>

Patient Information<\/h3>

Patient Full Name:<\/strong> ______________________________________<\/p>

Date of Birth:<\/strong> __________________________________________<\/p>

Mailing Address:<\/strong> ________________________________________<\/p>

Phone:<\/strong> ________________________________________________<\/p>

Email:<\/strong> ________________________________________________<\/p>

Estimate Details<\/h3>

Date Estimate Provided:<\/strong> _________________________________<\/p>

Method Provided:<\/strong>
\u2610 Paper
\u2610 Email
\u2610 Portal
\u2610 Other: ______________________________________<\/p>

Scheduled Service Date:<\/strong> _________________________________<\/p>

Scheduled Time:<\/strong> ________________________________________<\/p>

Provider:<\/strong> Change in Entropy Hypnotherapy<\/p>

Provider Address:<\/strong>
2862 Change Street, Unit A
Los Alamos, NM 87544<\/p>

Provider Phone:<\/strong> (907) 278-1180<\/p>

Provider Email:<\/strong> jennifer@change-in-entropy.com<\/a><\/p>

Patient Status<\/h3>

\u2610 Uninsured
\u2610 Self-pay, choosing not to use insurance for this service<\/p>

Description of Expected Items and Services<\/h3>
Item \/ Service<\/th>CPT \/ Internal Code, if used<\/th>Quantity<\/th>Expected Charge<\/th><\/tr><\/thead>
Initial hypnotherapy consultation<\/td>__________<\/td>____<\/td>$__________<\/td><\/tr>
Standard hypnotherapy session<\/td>__________<\/td>____<\/td>$__________<\/td><\/tr>
Follow-up session<\/td>__________<\/td>____<\/td>$__________<\/td><\/tr>
Intake \/ assessment time<\/td>__________<\/td>____<\/td>$__________<\/td><\/tr>
Written summary or administrative form, if applicable<\/td>__________<\/td>____<\/td>$__________<\/td><\/tr>
Other: __________________________<\/td>__________<\/td>____<\/td>$__________<\/td><\/tr><\/tbody><\/table><\/div><\/div>

Estimated Total Expected Charges:<\/strong> $________________<\/strong><\/p>

Notes About This Estimate<\/h3>

This Good Faith Estimate includes only the expected charges for services provided by Change in Entropy Hypnotherapy<\/strong>. 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.<\/p>

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.<\/p>

Patient-Provider Dispute Resolution Notice<\/h3>

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

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.<\/p>

For questions about your rights or the dispute process, contact:<\/p>

CMS \/ Federal No Surprises Help<\/strong>
Phone: 1-800-985-3059<\/strong>
Email: FederalPPDRQuestions@cms.hhs.gov<\/a><\/strong><\/p>

Important Patient Information<\/h3>

Keep a copy or photo of this form for your records.<\/p>

This form is an estimate only. It is not a bill.<\/p>

Patient Acknowledgment of Receipt<\/h3>

I acknowledge that I received this Good Faith Estimate.<\/p>

Patient Signature:<\/strong> ______________________________________<\/p>

Date:<\/strong> _________________________________________________<\/p>

Personal Representative, if applicable<\/h3>

Name:<\/strong> _________________________________________________<\/p>

Relationship to Patient:<\/strong> __________________________________<\/p>

Signature:<\/strong> _____________________________________________<\/p>

Date:<\/strong> _________________________________________________<\/p>

Practice Use Only<\/h3>

Prepared By:<\/strong> ___________________________________________<\/p>

Date:<\/strong> _________________________________________________<\/p>

Revision \/ Update Issued On:<\/strong> _____________________________<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"

Change in Entropy HypnotherapyWebsite: https:\/\/www.change-in-entropy.com\/Effective Date: March 17, 2026Last Updated: March 17, 2026 Contact InformationChange in Entropy Hypnotherapy2862 Change Street, Unit ALos Alamos, NM 87544Email: jennifer@change-in-entropy.comPhone: (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 […]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-299","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/pages\/299","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/comments?post=299"}],"version-history":[{"count":3,"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/pages\/299\/revisions"}],"predecessor-version":[{"id":302,"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/pages\/299\/revisions\/302"}],"wp:attachment":[{"href":"https:\/\/www.change-in-entropy.com\/index.php\/wp-json\/wp\/v2\/media?parent=299"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}