No Surprise Act Policy

No Surprise Act Policy

According to, the No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers

As a Direct-Pay facility, Mind and Body Family Wellness does not participate in any insurance plans. We will provide you with a Good Faith Estimate when you schedule your first patient visit to our office for Chiropractic Care. The Good Faith Estimate complies with the Department of Health and Human Services (HHS) No Surprises Act.


The Good Faith Estimate

The good faith estimate (or GFE) is a notification that outlines an uninsured (or self-pay) individual’s expected charges for a scheduled or requested item or service.

About the Good Faith Estimate:

This is not a contract. It does not obligate you to accept the services listed. The purpose of the Good Faith Estimate you are receiving is to provide you with an approximate cost of services you will receive from our practice that will not be paid by health insurance. Reasonably expected costs have been included in your estimate and are based on information known to our practice when it was prepared.

Any unknown or unexpected costs that may arise during treatment due to complications or unusual circumstances have NOT been included in this estimate. If they occur, and you are billed at least $400 above the amount indicated on this Good Faith Estimate (per provider), federal law allows you to dispute (appeal) your invoice for services in the following two ways:


  1. Contact Us: You may direct any questions or concerns you have regarding this estimate or any invoice to our practice. Please find our contact information below. Federal law permits you to ask that we update your invoice to match the Good Faith Estimate you received. You can also ask to negotiate the invoice amount or inquire about the availability of financial assistance.


  1. File a Formal Dispute Resolution: You may also file a formal dispute online with the Centers for Medicare & Medicaid Services (CMS) ( or by calling 1-800-985-3059.

    If you choose to file a formal dispute resolution, you must start the process within 120 calendar days of the date on the original invoice you receive. There is a $25 fee to use the dispute process. If your dispute is approved, you may be eligible to pay the lower amount on the Good Faith Estimate you received. If it is not approved, you will be obligated to pay the higher invoiced amount.

    IMPORTANT: It is recommended that you keep a hard or electronic version of this Good Faith Estimate in a safe place. You may need it should you choose to file a formal dispute.

Thank you for trusting us with your medical care. Please find your Good Faith Estimate on the back of this page. If you have any questions about this Good Faith Estimate or future invoices, please do not hesitate to contact us:


Karen Davenport, Office Manager
Mind and Body Family Wellness
12351 W 96th Terrace
Suite 207
Lenexa, KS 66215

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