GOOD FAITH ESTIMATE NOTICE

Under Section 2799B-6 of the Public Health Service Act, the “No Surprises Act,” you have a right to receive a “good faith estimate” explaining how much your therapy services will cost. Healthcare providers are required to provide clients who do not have insurance or who choose not to use their insurance for therapy services with an estimate of the cost of those services.

• You have the right to receive a Good Faith Estimate for the total cost of therapy services

• Make sure your therapist gives you a Good Faith Estimate in writing at least 1 business day before your appointment. You may also ask your therapist for a Good Faith Estimate before you schedule an appointment.

• If you receive a bill that is at least $400 more than your Good Faith Estimate you can dispute the bill.

• Make sure to save a copy 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 HHS at 1-800-958-3059.

House Bill 4224 (89th Regular Session) Section 181.105 of the Health and Safety Code

Requesting Medical Records

In accordance with Texas House Bill 4224 (89th Regular Session) and Section 181.105 of the Texas Health and Safety Code, clients may request copies of their medical records under the following guidelines:

How to Request Records

All requests for medical records must be submitted in writing. Verbal requests cannot be accepted. Written requests should include:

• Client’s full name

• Date of birth

• Specific records being requested

• Preferred method of delivery (electronic or paper, if applicable)

• Client signature and date

Written requests may be submitted via secure email, client portal, mail, or in person.

Processing Time

Once a complete written request is received, records will be provided within 30 days, as permitted by Texas law.

Fees

A fee may be associated with the preparation and release of medical records, in accordance with state guidelines. Any applicable fees will be communicated prior to release.

Record Retention

Medical records are retained in compliance with Texas law:

• Adults: Records are maintained for 7 years from the date of last service

• Minors: Records are maintained for 5 years after the client turns 18

After the required retention period, records may be securely destroyed.

If you have questions about requesting records, please contact our office for assistance.

Complaints

If a client believes their rights under Texas Health & Safety Code §181.105 have been violated, they may file a consumer complaint with the Texas Office of the Attorney General. Information on filing a complaint is available through the Office of the Attorney General of Texas. Please visit their website for more information.

Filing a Complaint Against a Licensee

In accordance with Texas House Bill 4224 (89th Regular Session) and the rules of the Texas Behavioral Health Executive Council (BHEC), clients have the right to file a complaint regarding the professional conduct of a licensed mental health provider. Complaints against a licensee must be submitted directly to the Texas Behavioral Health Executive Council (BHEC). Complaints must be made in writing and should include sufficient information to identify the licensee and describe the nature of the concern.

Contact Information for BHEC

Texas Behavioral Health Executive Council

333 Guadalupe Street, Suite 3-900

Austin, Texas 78701

Phone: (512) 305-7700

Information and complaint forms are available on the Texas Behavioral Health Executive Council website.