The Good Faith Estimate 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 Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
The Good Faith Estimate does not include services not provided by your provider that you may need and that your provider may recommend. For instance, the Good Faith Estimate does not include the cost of seeking medication for mental health.
The Good Faith Estimate is an estimate for services only and does not include other fees, such as fees for cancelling less than 24 hours in advance or no shows. These fees are outlined in the informed consent that is signed before the start of therapy services and that you have control over.
The Good Faith Estimate is not a contract and does not obligate you to receive the services listed nor does it obligate you to receive the services listed by this provider.
If you are billed for more than this Good Faith Estimate, 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 Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, 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 (approximately 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 Good Faith Estimate. 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 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059.
Keep a copy of your Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.