No Surprises Act (“Good Faith Estimate”)
You have the right to receive a “Good Faith Estimate” explaining how much your care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- You may obtain a good faith estimate upon request prior to scheduling an initial appointment and/or before you schedule an item or service. *It is difficult and at times impossible to estimate how many appointments you will need until your concerns are evaluated.
- You are free to discontinue services at any time. Additionally, services may be terminated by the provider as outlined in the informed consent document.
- Fees are listed in the informed consent and will remain in effect for 12 months unless otherwise stated. *A service fee schedule is included below.
- 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, visit www.cms.gov/nosurprises or call 800-985-3059.
Service Fee Schedule
Appointment Type & Frequency
*Rates based on current 2022 fees