Good Faith Estimate Statement
Your right to a Good Faith Estimate
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or who are not seeking to file a claim with their plan or coverage, both orally and in writing, of their ability to receive a "Good Faith Estimate" of expected charges, upon request or at the time of scheduling health care items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any nonemergency 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 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.
About this estimate
This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychiatric visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your clinician.
You are entitled to disagree with any recommendations made to you concerning your treatment, and you may discontinue treatment at any time.
Questions or disputes
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 or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.
Initiating the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.