This page explains your right to receive a Good Faith Estimate of the expected costs of your therapy services. Please review this information to understand your rights and how to request an estimate.
Effective January 1, 2022, a ruling went into effect called the “No Surprises Act” which requires practitioners to provide a “Good Faith Estimate” (GFE) about out-of-network care. The “Good Faith Estimate” works to show the cost of items and services that are reasonably expected for your health care needs for an item or services, a diagnosis, and a reason for therapy. 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. You could be charged more if complications or special circumstances occur and will be provided a new “Good Faith Estimate” should this occur with 30 days’ notice of the change of fee and provide options regarding continuing, transferring, or discontinuing services. If this happens, federal law allows you to dispute (appeal) the bill if you and your therapist have not previously talked about the charge and you have not been given an updated “Good Faith Estimate.”
Under Section 2799B-6 of the Public Health Service Act (PHSA), health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request, or at the time of scheduling health care items and services to receive a “Good Faith Estimate” of expected charges.
The Good Faith Estimate does not include services not provided by your provider that you may need and that your provider may recommend. For instance, the Good Faith Estimate does not include the cost of seeking medication for mental health. The Good Faith Estimate is an estimate for services only and does not include other fees, such as fees for cancelling less than 24 hours in advance. These fees are outlined in the informed consent that is signed before the start of therapy services and that you have control over. This Good Faith Estimate is not a contract and does not obligate you to receive the services listed nor does it obligate you to receive the services listed by this provider.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed 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 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059.
Kaylee Criswell, LPC-S, NPI: 1730735226, EIN: 871431663, Texas License: #80078
Jorge Garcia, LPC-S, NPI: 1417521758, EIN: 871431663, Texas License #80057
Mary Bennett, LPC-S, NPI: 1508412834, EIN: 871431663, Texas License #78829
Caitlin Gallegos, LPC, NPI:1508431339, EIN: 871431663 , Texas License #85279
Rachel Judd, LPC, NPI: 1659126332, EIN: 871431663, Texas License #89359
Sonia Noorany, LPC, NPI: 1396458089, EIN: 871431663, Texas License #88541
Neha Asif Qattan, LMFT, NPI: 1003485814, EIN: 871431663, Texas License #204260
Angelica Burgess, LPC, NPI: 1376397562, EIN: 871431663, Texas License #87093
Sarah Ziske, LPC Associate, Supervised by Dr. Jessica Endres, LPC-S; NPI: 1083426365, EIN: 871431663, Texas License #96642, and Jorge Garcia, LPC-S, NPI: 1417521758, EIN: 871431663, Texas License #80057
Carson Vasile, LPC Associate, Supervised by Mary Bennett, LPC-S; NPI: 1235960717, EIN: 871431663, Texas License #100103
Jolian George, LPC Associate, Supervised by Mary Bennett, LPC-S; NPI: 1104763911, EIN: 871431663, Texas License # 98557
Benjamin Stanzell, LPC, NPI: 1538027115, EIN: 871431663, Texas License #95473
Services are delivered at the physical locations: 8205 Mid Cities Blvd Suite 300 North Richland Hills, TX 76182, 3509 Hulen St Ste 208, Fort Worth, TX 76107, or via Telehealth. Location codes are POS 11 for office or 02 for Telehealth/ 10 for Telehealth Provided in Patient Home.
As therapists, we must diagnosis clients for both ethical, legal, and insurance reasons -- as well as required by the "No Surprises Act." This diagnosis is only to satisfy the federal requirement for this form and is not a formal psychological diagnosis. A formal diagnosis occurs after an assessment has been completed, which typically occurs 1-5 sessions after beginning psychotherapy.
Common Diagnosis Codes used at Luxx Therapy, PLLC:
Z71.9 Other counseling or consultation
F41.1 Generalized anxiety disorder
F43.23 Adjustment disorder with mixed anxiety and depressive mood
F33.1 Major depressive disorder, recurrent, moderate
F43.22 Adjustment disorder with anxiety
Luxx Therapy recognizes every client's therapy journey is unique. Together we will continually assess the appropriate frequency of therapy and will work to determine when you have met your goals and are ready for discharge. How long you need to engage in therapy and how often you attend sessions will be influenced by many factors including: Your schedule, availability, and life circumstances, therapist availability, ongoing life challenges (may increase or decrease frequency of sessions), the nature of your specific challenges and how you address them, and personal finances.
The counseling process is different for every person. Some clients may have counseling for 6-10 sessions and feel they are significantly helped. Others may need longer-term therapy. You and your therapist will continually assess the appropriate
frequency of therapy and will work together to determine when you have met your goals and are ready for discharge.
Your therapy needs may vary throughout the year. You may need less or more frequent sessions, which would impact this estimate accordingly. You may also discontinue therapy at any time. For example, if you were to attend weekly sessions for 52 weeks (without breaks, holidays, sickness, etc.) with Kaylee Criswell, LPC-S, your estimated total for services would be $150 x 52 = $8,320 for the year. For example, if you were to attend weekly sessions for 52 weeks (without breaks, holidays, sickness, etc.) your estimated total for services with our other LPCs and LPC-Ss would be $150 x 52 = $7,800 for the year. If you were to attend weekly sessions for 52 weeks (without breaks, holidays, sickness, etc.) your estimated total for services with an LPC Associate would be between $125 x 52 = $6,500, or $150 x 52 = $7,800 for the year. Our counselors also charge the same rate for their sessions if the session is canceled within 24 hours of the appointment, or you do not appear for the appointment.
Service Rates for Kaylee Criswell, LPC-S
Intake (90791) $160.00
Weekly Individual Therapy 53+ minutes (90837) $160
Individual Therapy 38-52 minutes (90834) $160.00
Individual Therapy 16-37 minutes (90832) $160.00
Family without patient (90846) $160.00
Family with patient (90847) $160.00
No-show/ Late Cancel Fee $160 per occurrence
Service Rates for Mary Bennett, LPC-S; Jorge Garcia, LPC-S; Caitlin Gallegos, LPC; Neha Asif Qattan, LMFT; Sonia Noorany, LPC; Rachel Judd, LPC; Angelica Burgess, LPC; Benjamin Stanzell, LPC
Intake (90791) $150.00
Weekly Individual Therapy 53+ minutes (90837) $150
Individual Therapy 38-52 minutes (90834) $150.00
Individual Therapy 16-37 minutes (90832) $150.00
Family without patient (90846) $150.00
Family with patient (90847) $150.00
No-show/ Late Cancel Fee $150 per occurrence
Service Rates for Sarah Ziske, LPC Associate, Jolian George, LPC Associate, and Carson Vasile, LPC Associate
Intake (90791) $125.00
Couples Intake (90791) $150.00
Weekly Individual Therapy 53+ minutes (90837) $125.00
Individual Therapy 38-52 minutes (90834) $125.00
Individual Therapy 16-37 minutes (90832) $125.00
Family without patient (90846) $125.00
Family with patient (90847) $125.00
Couples Therapy (90847) $150.00
No-show/ Late Cancel Fee $125 per occurrence, $150 for couples
Service Rates for Sarah Ziske, LPC Associate in Group Therapy
Intake Session $50.00
Ongoing Sessions $50.00
No-show/ Late Cancel Fee $50
