This Good Faith Estimate is good for 12 months from the date it was issued. If your care extends beyond one year, you will be given a new estimate. All sessions require separate scheduling and are done with your provider. Scheduling with your provider indicates that you are consenting to another session at the session cost listed here. Clients may receive these services at one or more of the following locations.
734 Wilcox St., Ste 202 Castle Rock, CO 80104
7200 S. Alton Wy Ste A120 Centennial, CO 80112
355 LaBonte St. Dillon, CO 80435
The Good Faith Estimate is not a contract and does not require the client to obtain services from any of the providers or facilities identified in the Good Faith Estimate. In addition, the Good Faith Estimate does not require the provider or facility to provide the services listed.
Your provider may recommend additional services that must be scheduled or requested separately. The Good Faith Estimate does not include additional fees that can be incurred during the course of treatment, such as cancellation fees, no-show fees, letter writing, phone calls, and the like. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. If complications or special circumstances occur, you could request more services and then be charged more.
The client has the right to initiate the client-provider dispute resolution process if the actual billed charges are over $400 more than the expected charges included in the Good Faith Estimate. You may contact Envision Counseling Clinic to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance 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 4 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 Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call the Health and Human Services at 1-877-696-6775.