Good Faith Estimate and Dispute Process Disclaimer 

Kristen Henshaw, LPC with Praxis Thriving, PLLC / Dissociation Therapy Austin provides good  faith estimates to all clients in accordance with the No Surprises Act. The 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 costs that might 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. 

You may contact the health care provider or facility 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 of 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. 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.