YOUR RIGHT TO A GOOD FAITH ESTIMATE Under federal law, you have the right to receive a Good Faith Estimate explaining how much your medical care will cost. Health care providers and facilities are required to provide this estimate to individuals who: Do not have health insurance, or Are not using their insurance to pay for services, or Are not enrolled in a federal health care program, and Are receiving non-emergency healthcare services WHAT IS A GOOD FAITH ESTIMATE? A Good Faith Estimate is a written document that explains the expected total cost of non-emergency healthcare services. This includes: Therapy or clinical services Related services provided in conjunction with your care Fees for tests, supplies, or other items that are reasonably expected to be part of your treatment WHEN YOU WILL RECEIVE YOUR ESTIMATE You have the right to receive a Good Faith Estimate: At least 1 business day before your scheduled service, or Upon request, even if you have not yet scheduled a service You may also request estimates from any other provider involved in your care. BILLING PROTECTION If you receive a bill that is at least $400 more than the amount listed in your Good Faith Estimate, you have the right to dispute the bill. You should: Save a copy or take a picture of your Good Faith Estimate Compare it to the final bill you receive HOW TO DISPUTE A BILL If you believe you have been billed incorrectly, you may initiate a dispute through the U.S. Department of Health and Human Services (HHS). More information is available at: https://www.cms.gov/nosurprises CONTACT INFORMATION If you have questions about your Good Faith Estimate or wish to request one, please contact: The Family Room Wellness Associates Email: jason@thefamilyroomsfl.com Website: https://www.thefamilyroomsfl.com
ACKNOWLEDGMENT By scheduling or receiving services, you acknowledge that you have been informed of your right to receive a Good Faith Estimate under federal law.
