Under Section 2799B-6 of the Public Health Act, the “No Surprise Act,” you have the right to receive a “good faith estimate” explaining how much your therapy services will cost. Healthcare providers are required to provide clients who do not have insurance or who choose not to use their insurance for therapy services with an estimate of the cost of these services. The total cost of each client will vary depending on length of time andfrequency of sessions that occur throughout the therapeutic relationship as determined by the initial assessment and continued evaluation of treatment needs and progress. A detailed list of possible services is provided below. This estimate is valid for the next 12 months. Should any fee changes occur, or upon your request, you will be provided a new Good Faith Estimate.

Possible Client Services

Intake Session (90791)

Individual Counseling (90834 or 90837)

Family Counseling (90846 or 90847)

Details of Fees and Services

Intake Session (90797), $135/session, 50 minutes

Individual Counseling (90834), $135/session, 45 minutes

Individual Counseling (90837), $135/session, 50 minutes

Family counseling with client present (90847), 50 minutes

Family Counseling without client present (90846), 50 minutes

Provider Information

Rochelle Brown

Texas LPC License #85975

National Provider Identifier (NPI): 1043028442

Taxpayer Identification Number (TIN): 92-3053166

Disclaimer

This Good Faith Estimate shows the costs of services that are reasonably expected for your health care needs. The estimate is based on information known at the time the estimate was created. This Good Faith Estimate does not include any unknown or unexpected cost that may arise during treatment. You could be charged more if complications or special circumstances offucr. It this happens, federal law allows you to dispute (appeal) the bill. Please note that this is only an estimate. Any services scheduled separately or in addition to the therapy services listed above are not reflected in this Good Faith Estimate. This estimate does not oblige you to obtain these services.

Dispute Process

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the therapist to let them know the billed charges are higher than the Good Faith Estimate. You may ask for an updated bill to match the Good Faith Estimate or ask to negotiate the bill.

You may also start a dispute resolution process with the US Department of Health and Human Services (HHS). If you chose to utilize the dispute resolution process, you must start the dispute resolution process within 120 calendar days (approximately 4 months) of the date of the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing the 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 practice, you will have to pay a higher amount.

To learn more about the dispute process or to get applicable forms for the dispute process, do to www.cms.gov/nosurprises or call HHS at 1-800-958-3059.

For questions or learn about your rights to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.