Your Right to Receive a Good Faith Estimate of Expected Charges Under the No Surprises Act

 If you do not have insurance or choose not to use your insurance, We will provide a “Good Faith Estimate” (“GFE”) of how much our services will likely cost you upon request. If you are paying us directly for your services and you schedule at least 3 days in advance, we will provide a written GFE within 1 day of scheduling. If you schedule more than 3 days in advance, we will provide a written GFE within 3 business days after scheduling. To facilitate this we will send the GFE by e-mail if you provide an e-mail address.

 We will inform you in advance with a new GFE if we plan to increase our fees or we anticipate your costs exceeding your original GFE.  If we don’t and we bill you more than $400 in excess of your GFE without informing you in advance, you will have a right to dispute our bill through a federal dispute resolution process. You will need to provide a copy of your GFE to open a dispute, so we recommend that you save and/or print your GFE for future reference.

 To request a GFE, please contact us.

For questions or more information about your right to a Good Faith Estimate,  visit www.cms.gov/nosurprises/consumers,
email [email protected], or call 1-800-985-3059.

PLEASE NOTE:

A Good Faith Estimate (GFE) will be provided for the initial visit which will include an examination to determine what the situation is and what level of care might be needed.  If appropriate and consented to, treatment might be provided during that first visit.  The cost of that first treatment will be included in the GFE provided when the first appointment is scheduled. 

A separate Good Faith Estimate will be provided for the projected treatment plan following that initial visit.  If the condition changes or progress is not as anticipated, a new GFE will be provided for such situations.

A Good Faith Estimate under this law is only applicable to uninsured individuals or individuals who choose not to bill their insurance and pay out of pocket.

A Good Faith Estimate is an ESTIMATE.  It is not defining of what the actual charges may be.

A Good Faith Estimate is not a contract or "promise" to provide services for that estimated cost.

There may be additional services or items needed in the care of a patient that are not listed in the Good Faith Estimate.  When those situations arise a separate GFE will be provided for those services or items and those charges will be above and beyond the existing GFE.

The patient always has the right to decline any services if the Good Faith Estimate is more than the patient might expect or choose to accept.

A person who has insurance but has not used it for the some of the period covered by the GFE, may choose later to start billing services to the insurance carrier.  When this is done, the previously provided services under the GFE will not be billable to the insurance, but any further services after notification will be billed to the insurance.  This choice also voids the GFE and any ability to dispute the charges through the No Surprises Act.

If the charges for the listed services within a Good Faith Estimate exceed the estimate by more than $400, the patient has the right to file a patient-provider dispute resolution process through the Federal Site listed above.  If a patient initiates such a dispute, it will not interrupt the care nor create any change in the quality of care provided while the matter is being settled.

If there is a dispute the patient and provider can work together to find a resolution without resorting to the Federal resolution process.

If a patient has any unanswered questions about the Good Faith Estimate or any of the patient's rights under the No Surprises Act, we will be happy to discuss these and provide guidance to the Federal Resolution process.