Posted on December 30, 2021
Notice of Counseling/ Therapy Good Faith Estimate
Information about Good Faith Estimates for all self-pay Ohana Behavioral Health clients have a right to receive a Good Faith Estimate per Federal law as of January 1, 2022.
A Good Faith Estimate enumerates the expenses you can reasonably expect to pay for your mental health care services provided by Ohana Behavioral Health and its clinicians. The estimate is created based upon the information known at the time the estimate is first created. It does not include unknown or unexpected costs that may arise during treatment.
It is possible you may incur more charges than the estimate enumerates if complications or special circumstances arise. If this happens, the Federal law provides you a right to dispute your bill. If you are billed for $400 or more than your Good Faith Estimate, you have the right to dispute the bill. You may contact Ohana Behavioral Health directly to if you are billed charges that exceed the Good Faith Estimate. You can request to update your bill to match the Good Faith Estimate, request to negotiate the bill, or you may request information about financial assistance availability.
You also have the right to initiate 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 from the date on the original bill. There is a $25 fee to use the dispute process. If the dispute-reviewing agency agrees with you, you will be responsible for the amount provided on your Good Faith Estimate. If the agency disagrees with your dispute and agrees with the fees charged by me that exceed the Good Faith Estimate, you will have to pay the higher amount charged.
To learn more visit www.cms.gov/nosurprises or call HHS at (800) 368-1019. Your estimate is not a contract. You are not obligated to receive services from Ohana Behavioral Health. Ohana Behavioral Health Admin can provide you with alternative referrals at your request at any time.
To inquire about our schedule of standard fees for our clinical services for clients who are self-pay, please email the office: office@ohanabehavioralhealth.com. The quote that you receive will be on your Good Faith Estimate. All of our other fees are stated in our Service Agreement paperwork.
