Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. 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, examinations, office visits, prescription drugs, and equipment (items or services reasonably expected to be furnished by this practice). When you will receive your estimate: A Good Faith Estimate must be provided within 3 business days if you request one. If you schedule an item or service, your Good Faith Estimate must be furnished within 1 business day of scheduling care to be provided in at least 3 business days, or within 3 business days of scheduling care to be provided in at least 10 business days. In all cases, make sure your health care provider gives you a Good Faith Estimate in writing at least one (1) 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 your bill is higher than expected: If you receive a bill that is at least $400 more than your Good Faith Estimate for a given provider or facility, federal law allows you to dispute the bill. You may contact us directly to let us know the billed charges are higher than your Good Faith Estimate, ask us to update the bill to match the estimate, negotiate the bill, or ask whether financial assistance is 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 this process, you must start it within 120 calendar days (about 4 months) of the date on your original bill. There is a $25 fee to use the dispute process. If the reviewing entity agrees with you, you will pay the price listed on your Good Faith Estimate, less the $25 fee; if it agrees with us, you will pay the higher billed amount. While a dispute is pending, the bill cannot be sent to collections (or collection efforts must stop if it already has), and no late fees may accrue on the disputed amount. Make sure to save a copy or picture of your Good Faith Estimate. You will need it if you wish to dispute a bill. For questions or more information about your right to a Good Faith Estimate or the dispute resolution process, visit www.cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.

This notice is based on the HHS/CMS model “Good Faith Estimate for Health Care Items and Services” disclaimer (CMS-10791) and 45 CFR § 149.610, and reflects the No Surprises Help Desk number published at cms.gov/nosurprises/contact-us as of the date this document was prepared. It is provided for general informational purposes and is not legal advice; please confirm current requirements and contact information with CMS or your own counsel before publishing.