Good Faith Estimate Statement
The Balance Within Counseling
Elizabeth (Beth) Reece, LPC, CAADC, SAP
YOUR RIGHT TO A GOOD FAITH ESTIMATE
If you do not have health insurance for these services, or you have commercial insurance but choose not to use it, you have the right to receive a written Good Faith Estimate of expected charges before receiving care.
You may ask for a Good Faith Estimate before scheduling care or at any time.
If you schedule care at least 3 business days in advance, federal rules generally require the estimate to be provided within the applicable federal timeframe.
A Good Faith Estimate is not a bill and is not a contract. It does not require you to receive services from this practice.
Keep a copy of your estimate so you can compare it with your bills.
IF YOUR BILL IS HIGHER THAN THIS ESTIMATE
If a bill from this provider is at least $400 more than the expected charges shown on the Good Faith Estimate, you may be eligible to use the federal Patient-Provider Dispute Resolution process. You generally must start the dispute within 120 calendar days of the date on the initial bill. Starting a dispute will not affect the quality of care you receive.
You may first contact The Balance Within Counseling to ask about the difference or request that the bill be reviewed. For federal information about Good Faith Estimates and the dispute process, visit CMS at www.cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.
WHEN YOU SHOULD RECEIVE A GOOD FAITH ESTIMATE
If care is scheduled 3-9 business days in advance: generally within 1 business day after scheduling.
If care is scheduled 10 or more business days in advance: generally within 3 business days after scheduling.
If you request an estimate before scheduling: generally within 3 business days after the request.
The Balance Within Counseling | Elizabeth (Beth) Reece, LPC, CAADC, SAP
41100 Plymouth Road, Suite B1-215, Plymouth, Michigan 48170 | 734-735-8387
thebalancewithincounseling@gmail.com | www.thebalancewithincounseling.com