STANDARD NOTICE

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 or 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 800-368-1019

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 or 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 800-368-1019

More Details Regarding Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act:

As of 1/1/2022, all self-pay clients who do not intend to seek insurance reimbursement OR who have no "out of network" benefits have the right to a Good Faith Estimate (GFE). 

The GFE shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The GFE does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. 

Federal law allows you to dispute (appeal) the bill if you receive charges in excess of your expectations. If you are billed for $400 or more than your GFE, 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 GFE. You can ask them to update the bill to match the GFE, 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 GFE. 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 HHS at (800) 368-1019. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit http://www.cms.gov/nosurprise or call (800) 368-1019. 

If you are not using your insurance for in- or out-of-network benefits, you will receive a GFE prior to the start of your treatment. Keep a copy of this GFE in a safe place or take pictures of it. You may need it if you are billed a higher amount than what you agreed to pay. 

This estimate is not a contract. You are not obligated to receive services at this facility or by this provider. Our office can provide you with alternative referrals at your request.

As of 1/1/2022, all self-pay clients who do not intend to seek insurance reimbursement OR who have no "out of network" benefits have the right to a Good Faith Estimate (GFE).
 

The GFE shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The GFE does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur.
 

Federal law allows you to dispute (appeal) the bill if you receive charges in excess of your expectations. If you are billed for $400 or more than your GFE, 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 GFE. You can ask them to update the bill to match the GFE, 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 GFE. 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 HHS at (800) 368-1019. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit http://www.cms.gov/nosurprise or call (800) 368-1019.
 

If you are not using your insurance for in- or out-of-network benefits, you will receive a GFE prior to the start of your treatment. Keep a copy of this GFE in a safe place or take pictures of it. You may need it if you are billed a higher amount than what you agreed to pay.
 

This estimate is not a contract. You are not obligated to receive services at this facility or by this provider. Our office can provide you with alternative referrals at your request.