No Surprises Act & Good Faith Estimate Notice
Your Right to Receive a Good Faith Estimate of Expected Charges
Under the No Surprises Act (NSA)
Practice: Mental Essence Counseling, PLLC
Provider: Acura Blaylock, MS, LPC-Associate
Supervised by: Dr. Carole Gilmore, PhD, LPC-S
Website: https://www.mentalessence.org
Email: acurablaylock@mentalessence.org
Your Rights Under Federal Law
Under the No Surprises Act, you have the right to receive a Good Faith Estimate (GFE) explaining the expected cost of your mental health services.
This applies if:
You do not have insurance, or
You choose not to use your insurance, or
You are self-pay for services.
Your Right to a Good Faith Estimate
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency services. This includes:
Therapy or counseling services
Psychological services
Any related administrative or service fees, if applicable
You may request a Good Faith Estimate before scheduling, at scheduling, or any time during your treatment.
Your Good Faith Estimate must be provided to you:
In writing,
No later than 1 business day before your scheduled appointment (for appointments booked 3+ days in advance), or
Within 3 business days of your request (if you ask for an estimate before scheduling).
If Your Bill Is Higher Than Expected
If you receive a bill that is $400 or more above your Good Faith Estimate, you have the right to:
File a payment dispute,
Have the bill reviewed, and
Potentially pay only the amount listed in the Good Faith Estimate along with any allowed dispute fees.
You must start your dispute claim within 120 days of receiving the bill.
Keep a Copy of Your Estimate
You will be provided a written Good Faith Estimate, and you have the right to:
Request updated estimates at any time
Keep copies for your personal records
More Information
For questions or more details about your right to a Good Faith Estimate, you may visit:
🔗 www.cms.gov/nosurprises
📧 Email: acurablaylock@mentalessence.org