Good Faith Estimate Request

Patient Name

Date of Birth

Date

Email Address

example@example.com

Phone Number

Please enter a valid phone number.

Appointment Reason

You may be eligible for Aspire’s sliding fee discount program which is based on household size and income.

Would you like to apply for Aspire’s sliding fee discount program?

YesNo

Have you scheduled an appointment?

YesNo

Please select the service(s) you wish to receive a good faith estimate on below.

Office VisitPsychiatric ServiceBehavioral Health ServiceOther

How would you like to receive your Good Faith Estimate?

Email (will be encrypted to protect your information)Patient PortalMailedPrinted for pick up in the office