No Surprises Act Disclosure Notice
Effective Date: January 1, 2025
A Better Version Collaborative Counseling
Your Rights and Protections Against Surprise Medical Bills
Under the No Surprises Act, you are protected from unexpected medical bills in the following ways:
No Surprise Billing for Emergency Services
If you receive emergency care from an out-of-network provider or facility, you cannot be billed more than your in-network cost-sharing amount (such as copayments, coinsurance, and deductibles).
No Balance Billing for Certain Services
If you receive treatment from an out-of-network provider at an in-network facility, you cannot be charged more than your in-network cost-sharing amount unless you provide written consent.
Good Faith Estimate for Uninsured or Self-Pay Patients
If you do not have insurance or choose not to use it, you have the right to receive a Good Faith Estimate of the expected costs before receiving non-emergency healthcare services.
Your Right to a Good Faith Estimate
If you are uninsured or choose to self-pay, we will provide you with a Good Faith Estimate, which includes:
- An estimated cost of services and treatment.
- Expected charges for any additional fees related to your care.
- A clear, itemized list of services in plain language.
This estimate will be provided:
- At least 3 business days in advance for scheduled services if the appointment is more than 3 days away.
- Upon request, even if you have not yet scheduled an appointment.
If your final bill is at least $400 more than your Good Faith Estimate, you have the right to dispute the charge.
Billing & Disputes
If you receive a bill that is higher than your Good Faith Estimate, you may:
- Contact us to discuss payment options or dispute the charge.
- File a dispute resolution request through the U.S. Department of Health and Human Services (HHS) within 120 days of receiving the bill.
Contact Information
For questions, to request a Good Faith Estimate, or to file a dispute, contact:
A Better Version Collaborative Counseling
📍 127 E Liberty Street, Suite 255, Wooster, OH 44691
📞 234-249-2427
📧 [email protected]
For more information about your rights, visit: www.cms.gov/nosurprises