Declaration of Practices and Procedures: Each Granberry Counselor has a Declaration of Practices and Procedures. Please click the name of your Counselor below, print out and read their form. Please sign the form and bring it with you to your appointment. Thank you.
"Right to Receive a Good Faith Estimate of Expected Charges"
Under the No Surprises Act
You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost.
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.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider, and any other provider you choose for a Good Faith Estimate before you schedule an item o.r service.
- 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 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 Granberry Counseling Centers at 318-345-8200.
These forms are available to you to read and fill out prior to your first visit.
New Client Information Sheet
Consent to use & disclose your health info
Mental Health Consumers' Rights
Request/Authorization to Release Confidential Records and Information
Covid 19 Consent
Good Faith Estimate Notice