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Good Faith Estimate

Please Note: The amounts listed are only an estimate; this is not an offer or contract for services.

This estimate shows the full estimated costs of the items or services listed.

It doesn’t include any information about what your health plan may cover.

This means that the final cost of services may be different than this estimate.

Contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay.

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*Please note that Place of Service (in office vs. telemental health) is not delineated above since the charges are identical

 BestLife Counseling, Consulting, and Training PLLC Services Practice Information:

ADDRESS: 875 Porter Rd, Bartonville, TX 76226

CONTACT PERSON: Rebecca Partridge, Ph.D., LMFT-Supervisor, Rebecca@bestlifecct.com

FEDERAL TAX ID: 87-0874700

GROUP NPI#: 1326714593

 

Disclaimer

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.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

 

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. 

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

  • You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

  • Make sure to save a copy or picture of your Good Faith Estimate.