Good Faith Estimate

Under the No Surprises Act (H.R. 133 – effective January 1, 2022), health care providers need to give clients or patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.

• This Good Faith Estimate (GFE) shows the costs of items and services you can reasonably expect for your health care needs. 

• You have the right to receive a GFE for the total expected cost of any non-emergency items or services. 

• The GFE does not include any unknown or unexpected costs that may arise during treatment. You may experience additional charges if complications or exceptional circumstances occur. 

• If you receive a bill at least $400 more than your GFE, you may dispute or appeal the bill.

  • You may contact the health care provider or facility listed to let them know the billed charges are higher than the GFE. You may ask them to update the bill to match the GFE, negotiate the bill, or ask if financial assistance is 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 four 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 GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. 

• Make sure your health care provider gives you a GFE within the following timeframes:

  • If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling;

  • If the service is scheduled at least ten business days before the appointment date, no later than three business days after the date of schedule; or

  • If the uninsured or self-pay client requests a GFE (without scheduling the service), no later than three business days after the date of the request. Healthcare providers must supply a new GFE within the specified timeframes if the patient reschedules the requested item or service.

Note: A Good Faith Estimate is for your awareness only and does not require immediate financial commitment or payment. 

To learn more, go to www.cms.gov/nosurprises or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you receive a bill in a higher amount.

If you have questions or concerns, please reach out.cConsumer Access to Health Care Records & Complaint Information

Consumer Access to Health Care Records & Complaint Information

Affect Counseling - Licensed Clinical Social Worker

In accordance with House Bill 4224 (89th Regular Session) and Texas Health & Safety Code §181.105, Affect Counseling provides the following information to assist consumers in:

* Requesting health care records

* Contacting the licensing authority

*Filing a consumer complaint

How to Request Your Health Care Records

Clients and former clients may request copies of their health care records from Affect Counseling using the form provided at the bottom of this page which is located on google docs.

Phone or Text 817-313-3348

Email (preferred): denise@affectcounsling.com

Mail: Affect Counseling
751 East Debbie Ln
Suite 105
Mansfield, TX 76063

To avoid delays, please include:

*Full name and date of birth
*Phone number and/or email address
*Description of records requested (entire record or specific dates)
*Preferred delivery method (secure email, mail, or pick-up)
*Your signature and date

If requesting records on behalf of another person, documentation showing legal authority (such as guardianship or medical power of attorney) is required.

Identity verification may be required to protect patient privacy.

Contact the Texas Behavioral Health Executive Council (Licensing Authority for Licensed Clinical Social Workers)

Affect Counseling is regulated by the Texas Behavioral Health Executive Council (BHEC).

You may contact the Council using the following webpage: https://bhec.texas.gov/contact-us/

Select Licensed Clinical Social Worker (LCSW) when submitting an inquiry.

File a Consumer Complaint with the Texas Attorney General

Consumers may file a complaint with the Texas Office of the Attorney General – Consumer Protection Division at:

https://www.texasattorneygeneral.gov/consumer-protection/file-consumer-complaint

Please include relevant dates, names, and supporting documentation if available.

Questions About House Bill 4224

For questions related to HB 4224, Texas Health and Human Services provides the following contact email: HCR_PRU@hhs.texas.gov