Good Faith Est

GOOD FAITH ESTIMATE FOR HEALTH CARE ITEMS AND SERVICES UNDER THE NO SURPRISES ACT

Under Section 2799B-6 of the Public Health Service Act, health care providers & health care facilities are required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage, both orally and in writing, upon request or at the time of scheduling health care items and services. A good faith estimate must be provided within 3 business days upon request. Information regarding scheduled items and services must be furnished within 1 business day of scheduling an item or service to be provided in 3 business days; and within 3 business days of scheduling an item or service to be provided in at least 10 business days.

Disclaimers

This Good Faith Estimate only provides an estimate of the charges for those items or services reasonably expected to be furnished to you upon your receipt of the scheduled/requested primary item or service. Actual items and service received in connection with the scheduled/requested primary item or service, and the charges stated in your bill, may differ from those items, services, and estimated charges listed in this Good Faith Estimate. Moreover, there may be additional items or services which Dr Stafford recommends as part of your course of care that you will be required to schedule separately which are not reflected in this Good Faith Estimate. This estimate is only valid for 30 days. If the actual charge for these services exceeds our estimate by the greater of: (i) $100; or (ii) 5%, we will provide a written explanation as to why the charges exceed the estimate. This Good Faith Estimate is not a contract and does not require you to obtain any of the items or services from any of the providers or facilities identified in this Good Faith Estimate. If you are uninsured or do not intend to submit your charges to your health plan (“self-paying”) and you are billed at least $400 more than this Good Faith Estimate, you have the right to dispute the bill. If you are uninsured or self-paying, you may contact the health care provider or facility to let them know the billed charges are higher than the Good Faith Estimate and 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. Uninsured or self-paying individuals may also start a dispute resolution process for uninsured with the U.S. Department of Health and Human Services (HHS). If you choose to do so, you must start the dispute process within 120 calendar days of the date on the original bill. There is a $25 fee to use the dispute resolution process for uninsured and self-paying individuals. 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 this process, go to www.cms.gov/nosurprises or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059.