Good Faith Estimate

Your rights under the No Surprises Act — understanding your estimated costs before care.

Right to Receive a Good Faith Estimate of Expected Charges

What Is a Good Faith Estimate?

Under the No Surprises Act, health care providers are required to give patients who don't have insurance or who are not using insurance an estimate of expected charges for medical services, including psychotherapy 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.

Who Is Eligible?

You may request a Good Faith Estimate if you:

  • Do not have health insurance, or
  • Have health insurance but choose not to use it for the scheduled service (self-pay).

A Good Faith Estimate is not required for emergency services or situations where insurance is being billed.

What Your Estimate Will Include

Your Good Faith Estimate will be provided in writing before your scheduled service and will include:

  • Expected charges for the primary service or procedure
  • Itemized list of related items and services reasonably expected in connection with your care
  • Diagnosis and service codes
  • Expected facility and provider charges
  • A disclaimer that the actual charges may differ from the estimate

Make sure to save a copy or take a picture of your Good Faith Estimate.

How to Request a Good Faith Estimate

1
Contact our officeLet us know if you would like a Good Faith Estimate before scheduling or at the time of scheduling your appointment.
2
Provide your informationShare details about the services or procedures you need so our team can prepare an accurate estimate.
3
Receive your estimateWe will provide your written Good Faith Estimate at least 1 business day before your scheduled service, or within 3 business days of your request if no service is yet scheduled.

Request a Good Faith Estimate

📞 301-202-2009

✉ patient_billing@precisionorthomd.com

If Your Bill Is Higher Than Your Estimate

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill.

You may contact us at the number or email above to let us know the billed charges are higher than the Good Faith Estimate. You can also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS):

HHS — Patient-Provider Dispute Resolution

🌐 cms.gov/nosurprises

📞 1-800-503-1465

The HHS dispute resolution process is available for bills that are at least $400 more than your Good Faith Estimate and for bills where you received the Good Faith Estimate at least 3 business days before the service was provided.

You are not required to use the dispute resolution process. You may also contact your state insurance commissioner or pursue other options available under your state's law.

Additional Information

For questions about your rights or for more information about the No Surprises Act, visit cms.gov/nosurprises or call 1-800-503-1465.

This notice was prepared in accordance with the requirements of 45 CFR Part 149 and the No Surprises Act (Division BB of the Consolidated Appropriations Act, 2021).