LifeMenders Counseling, PLLC
116 W 8th St, Ste 110
Georgetown, TX 78626
(512) 673-2192
GOOD FAITH ESTIMATE
Effective January 1, 2022, Congress passed the Public Health Service Act. Part of this act includes the new “No Surprises Act”, which aims to reduce the likelihood that patients may receive a “surprise” medical bill. The Act currently only applies to patients who choose NOT to use their health insurance (i.e. “self-pay”) and to patients who are NOT enrolled in a health plan for their mental health needs. It requires providers to inform patients of an expected charge for a service before the service is provided. To comply with this new law, prior to your initial appointment, you will be provided with our fees for the initial evaluation and for subsequent sessions. Each session will last approximately 45 to 50 minutes. If a session needs to be longer, costs will be shared prior to the visit.
Disclaimer
The information provided in this estimate is only an estimate. It is based on the information known at this time. Actual items, services, or charges may differ from the good faith estimate. Given the interpersonal nature of the therapeutic relationship and the many variables that can influence our work together, it is difficult to accurately predict the exact length of time we will need to address the concerns you have brought to my attention. After the initial evaluation and as we begin our work together, I will have a clearer picture of your specific diagnosis, treatment plan, and needs. Other charges could occur if special circumstances occur. This could include missed session fees, reports, letters, etc. All additional costs will be discussed ahead of time, and we will not proceed unless you consent to the charge.
Complaints
Please note that every patient has the right to initiate a patient-provider dispute resolution process if the actual billed charges substantially exceed (over $400) the expected charges included in the good faith estimate. You may call me to let me know that the billed charges are higher than the Good Faith Estimate. You can ask me to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there can be a payment plan initiated. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to start this process, you must start it within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on the Good Faith Estimate you were given. If the agency disagrees with you and agrees with the health care provider, you will have to pay the higher amount. To learn more and get a form to start the process, please go to www.cms.gov/nosurprises or call 800-985-3059. Please keep a copy of this Good Faith Estimate in a safe place. The good faith estimate is not a contract and does not require individuals to obtain the services from any of the providers or facilities identified in the good faith estimate. At any time, you can decide if you would like to use your health insurance and choose a provider in your plan’s network. Please let me know if you have any questions or concerns about the Good Faith Estimate information. You can call me at (512) 673-2192.