Good Faith Estimate Notice

Under the No Surprises Act (H.R. 133 - effective January 1, 2022), health care providers, including Integrated Unity Center Texas, are required to give clients who do not have insurance or are not using insurance an estimate of the bill for medical or mental health items and services.

 

What is a Good Faith Estimate?

 

The Good Faith Estimate (GFE) shows the costs of services that are reasonably expected for your mental health care needs. The estimate is based on the information known to us when we create the estimate. The GFE is provided to give you transparency regarding the expected costs of non-emergency services you receive from Integrated Unity Center Texas.

 

You have the right to receive a Good Faith Estimate for the total expected costs of any non-emergency services, including psychotherapy, counseling, and other mental health services.

 

Understanding Your Estimate:

 

• The Good Faith Estimate does not include any unknown or unexpected costs that may arise during your treatment. If complications or special circumstances occur, you may be charged more than the estimate provided.

• If your final bill exceeds the Good Faith Estimate by $400 or more per provider, you have the right to dispute the bill.

 

Dispute Resolution:

 

If you are billed more than $400 above your Good Faith Estimate, you may:

 

• Contact Integrated Unity Center Texas to let us know that the charges are higher than expected. We can discuss updating the bill, negotiating the charges, or exploring financial assistance options.

• Initiate a dispute resolution process through the U.S. Department of Health and Human Services (HHS). To do so, you must start the process within 120 calendar days (about 4 months) from the date of the original bill.

 

There is a $25 fee to start the dispute process. If the reviewing agency agrees with you, you will only have to pay the amount listed in your Good Faith Estimate. If they agree with the provider, you will be responsible for paying the higher amount.

 

For more information or to begin the dispute process, visit: www.cms.gov/nosurprises or call 1-800-985-3059.

 

Important Notes:

 

• This Good Faith Estimate is not a contract. It does not obligate you to accept the services listed or move forward with treatment at Integrated Unity Center Texas.

• Keep a copy of your Good Faith Estimate for your records. You may need it if you are billed more than $400 over the amount estimated.

 

If you have any questions or need further clarification regarding your Good Faith Estimate, please do not hesitate to contact Integrated Unity Center Texas at [icuc.clinic@gmail.com].

 

Feel free to adjust any specific service descriptions, contact details, or pricing information as needed for your practice.