Good Faith estimate

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost.

Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services.
If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For questions or more information about your right to a Good Faith Estimate, visit

www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-

800-985-3059.

PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.

Notice of electronic disclosure

Geneva Walker, LPC is a Covered Entity and must comply with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), the Health Information Technology for Economic and Clinical Health Act (“HITECH” or the “HITECH Act”), and Chapters 181 and 182 of the Texas Health & Safety Code. Please note that Chapter 181 of the Texas Health and Safety Code defines the term “Covered Entity” more broadly than does HIPAA in 45 C.F.R. §160.103. Covered entities as defined by Chapter 181 are required to comply with the applicable Chapter 181 provisions. If Geneva Walker, LPC obtains or creates information about your health, Geneva Walker, LPC is required by law to protect the privacy of your information. Protected health information (“PHI”) includes any information that relates to:

Your past, present, or future physical or mental health or condition;
Health care provided to you; and,
Past, present, or future payment for your health care.

Geneva Walker, LPC may not disclose your PHI electronically without your authorization unless allowed by law. For example, the practice may share your PHI through approved, secure electronic methods for the purpose of treatment, payment for health care services, or health care operations such as case management or care coordination.

Geneva Walker, LPC may not disclose PHI electronically without separate authorization from you or your personal representative for each disclosure unless the disclosure is for treatment, payment, health care operations, an insurance or HMO function, or as otherwise authorized under state or federal law.

For a complete list of reasons that Geneva Walker, LPC is allowed by law to share your PHI, please refer to the Notice of Privacy Practices. This Notice will be provided upon the first date of delivery of health care services to you and is available upon request.

Victorious Walk Counseling

Victorious Walk Counseling

Good Faith estimate

Notice of electronic disclosure

Victorious Walk Counseling

Victorious Walk Counseling

Good Faith estimate

Notice of electronic disclosure

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