No Surprise Act

The No Surprise Act was established to support federal protections against surprise medical bills. Alison Leslie, Empower Healing Counseling and Consulation will both orally and in writing provide a Good Faith Estimate (GFE) of expected charges for services recommended to address individual need.

In support of understanding of service agreements between client and agency, the GFE will be provided at time of client review of informed consents and completing intake documentation prior to beginning services. Before moving forward with counseling services.

This Good Faith Estimate shows the costs 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 costs
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 than 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 Human 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 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 this 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 .
For questions or more information about your right to a Good Faith Estimate
or the dispute process, visit www.cms.gov/nosurprises .