GOOD FAITH ESTIMATE

Mosaic Therapy Collective LLC

In compliance with the No Surprises Act, we are providing this Good Faith Estimate to inform you of the anticipated costs for your counseling services. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including counseling services. Upon request, we will provide you with a Good Faith Estimate within one business day.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Factors Affecting Cost: The cost of counseling services may vary based on factors such as the complexity of your case, the duration of sessions, and the type of counseling provided.
Limitations: This Good Faith Estimate is not a guarantee of final costs, and the actual charges may differ based on unforeseen circumstances during your counseling sessions.
Insurance Coverage: If you have health insurance, we will work with your insurance provider to determine your coverage. However, it is essential to verify your benefits directly with your insurance company to understand the specifics of your coverage.
Your Financial Responsibility: You are responsible for any remaining balance not covered by insurance. We recommend checking with your insurance provider to understand your out-of-pocket costs and coverage details.
Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call the Colorado Division of Insurance at 303-894-7490 or 1-800-930-3745 or contact our billing department at contact@mosaictherapyco.com or (720) 248-7318.

Acknowledgement: By continuing with your counseling services, you acknowledge that you have received this Good Faith Estimate notice.