LEGAL

Good Faith Estimate Notice

Your Right to Receive a “Good Faith Estimate”

Understanding the Cost of Your Health Care

Under federal law, health care providers are required to provide patients who do not have certain types of health care coverage or who are not using certain types of health care coverage with an estimate of their expected medical costs before services are provided.

Your Rights

  • You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes costs related to medical tests, prescription drugs, equipment, and hospital fees.

  • If you schedule a health care item or service at least three (3) business days in advance, your health care provider or facility must provide a Good Faith Estimate in writing within one (1) business day after scheduling.

  • If you schedule a health care item or service at least ten (10) business days in advance, your health care provider or facility must provide a Good Faith Estimate in writing within three (3) business days after scheduling.

  • You can also request a Good Faith Estimate before scheduling a health care item or service. The provider or facility must provide the estimate in writing within three (3) business days after your request.

  • If you receive a bill that is at least $400 more than the Good Faith Estimate provided by any provider or facility, you have the right to dispute the bill.

  • Be sure to keep a copy or picture of your Good Faith Estimate and any related bills.

Important Disclaimers

  • Additional services or items may be recommended during your course of care that are not included in the initial Good Faith Estimate and must be scheduled separately.

  • The Good Faith Estimate is only an estimate of what is reasonably expected to be provided at the time it is issued. Actual services, items, or charges may differ.

  • The Good Faith Estimate is not a contract and does not obligate you to receive services or items from the providers or facilities listed in the estimate.

  • You have the right to initiate a dispute if the actual billed charges are substantially higher than those included in the Good Faith Estimate.

  • If you wish to initiate a dispute, please contact our office. The dispute resolution process will not affect the quality of care you receive.

For More Information

For questions or more details about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

You may also contact Dr. Monica Argumedo at 224-344-1288 or md@1stresponsepsych.com for further assistance.