*The No surprise Act was signed into law in 2021, and is being enforced by the Public Health Service Act, January 1^st, 2022.

*All intake paperwork MUST be completed and turned in via email link that was sent at time of scheduling – at LEAST 48 hours prior to the appointment – so that benefits can be checked and confirmed. Both insurance based and private pay clients/patients may be subject to this law. The law ensures that you are fully aware of the cost associated with your diagnosis and treatment in any particular mental health or medical treatment facility.

*The No Surprises Act is subject to future revisions but is currently focused on healthcare providers making available to you a “good faith” estimate of the cost associated with your treatment to avoid you being charged with a bill you were unaware of.

*For example, If you are treated by Better Living Center for Behavioral Health and were seen by an out-of-network provider and received a major bill, you should have been informed of the possibility of this ahead of time or before the services occurred. This also applies to in-network providers who need to make you aware, as the client/patient.

DISCLAIMER

This Good Faith Estimate shows the cost of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

The Good Faith Estimate does NOT include any unknown or unexpected cost that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed for more that this Good Faith Estimate, you have the right to dispute the bill.

You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Humas Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date of the original bill.

A disclaimer that there may be additional items or services the convening provider or convening facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate.

A disclaimer that the information provided in the good faith estimate is only an estimate and that actual items, services, or charges may differ from the good faith estimate.

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. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 368-1019.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.

Keep a copy of this Good Faith Estimate in a safe place or take a picture of it. You may need it if you are billed a higher amount.