Good Faith Estimate

This estimate is for counseling services provided starting on the date designated in the signature below.

Under section 2799b-6 of the Public Health service a health care providers and health care facilities are required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in a plan or coverage.

The estimate below is the cost that is likely for most new patients.  Until therapist conducts an initial evaluation and begins to work with the client, they will not have a clear picture of client’s specific wants and needs. This estimate provides a framework of expectations for cost and duration of therapy. However, each client presents with their own unique needs, which the therapist will consider and accommodate. Client may need additional sessions beyond the scope of this estimate, which the therapist will be happy to provide.

If you have questions about this estimate, please contact Laura Pace at:

Phone: 214-924-2264 or

Email: laura@connectionscounselingtx.com

Details of the Estimate

The following is a detailed list of expected charges for counseling services.  The estimated costs are valid for 12 months from the date of this Good Faith Estimate.

Service, codes, and cost

Initial evaluation (90791) $175.00 per session

Psychotherapy (90837) $175.00 per session. Number of sessions TBD with client.

Total estimated cost determined with client in initial session.

Disclaimer

This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if special circumstances occur. If this happens, federal law allows you to appeal the bill. If you are billed for $400 more (per provider) than this Good Faith Estimate (GFE), you have the right to dispute the bill.

Consumer Complaints and Billing Disputes

If you have concerns about the professional conduct or services of a Licensed Professional Counselor, you have the right to file a complaint with the Texas Behavioral Health Executive Council (BHEC), the state agency that regulates LPCs and LCSWs. Information on how to file a complaint with BHEC is available upon request or on the BHEC website.

If you are uninsured or self-pay and receive a bill that is $400 or more higher than your Good Faith Estimate, you also have the right to initiate a federal patient-provider dispute resolution process under the No Surprises Act. This dispute process is administered by the U.S. Department of Health and Human Services (HHS), not BHEC. The dispute must be started within 120 calendar days of the date on the original bill and includes a filing fee. If the dispute is resolved in your favor, you will pay the amount listed on your Good Faith Estimate; if not, you may be responsible for the higher amount. More information and instructions are available at cms.gov/nosurprises or by calling 1-800-985-3059.

.This GFE is not a contract.  It does not obligate you to accept the services listed above.

By my signature below, I acknowledge that I have read and that I understand this document, and that any questions I had about this document were answered to my satisfaction, and that I was furnished a copy of this document.   By my signature below I agree to comply with all its terms and requirements, give consent for my therapist to work with me, and understand and agree to my financial obligations including the cancellation policy stated above.

Your Rights as a Client

As a client, you have the right to access your health records and to share concerns about your care. The Texas Behavioral Health Executive Council (BHEC) investigates and prosecutes professional misconduct committed by marriage and family therapists, professional counselors, psychologists, psychological associates, social workers, and licensed specialists in school psychology. You have the right to file a complaint regarding counseling services or the mishandling of your health information. Complaints may be submitted to the Texas BHEC. Information on how to obtain your records or file a complaint is available below.

• Getting Your Records
  You may request a copy of your counseling or health records at any time. Please contact our office for instructions on how to submit a request.

• Questions or Concerns About Licensing
  In Texas, concerns or complaints about Licensed Professional Counselors (LPCs) are handled by the Texas Behavioral Health Executive Council (BHEC):

  • Phone: 512-305-7700 or 1-800-821-3205

  • Email: Enforcement@bhec.texas.gov

  • Mailing Address:
    Texas Behavioral Health Executive Council
    Attn: Enforcement Division
    1801 Congress Ave., Ste. 7.300
    Austin, TX 78701

  • Further, if you have a concern about a consumer issue related to your health care or counseling services, you have the right to file a complaint with the Texas Attorney General’s Consumer Protection Division. This office helps protect Texans from unfair or deceptive business practices. You can find information about how to file a complaint and submit it online at texasattorneygeneral.gov/consumer-protection or request assistance from our office.

  • This information can also be found on the BHEC website (https://bhec.texas.gov)

If you have questions about any of these rights, please ask. We are always happy to help.