Good Faith Estimate Notice

Your Rights and Protections Against Surprise Medical Bills

Under the law, health care providers must give patients who don’t have insurance, or who are not using insurance, an estimate of the expected charges for medical items and services. This is called a Good Faith Estimate (GFE).

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 (if applicable).

• Receive the estimate in writing at least one (1) business day before your scheduled service. You can also ask your provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

Important things to know:

• The Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs. The estimate is based on information known at the time it is created.

• The Good Faith Estimate does not include any unexpected costs that may arise during treatment.

• The Good Faith Estimate is not a contract. You are not obligated to receive services from Soul Works Therapy & Wellness.

Dispute Rights:

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

• You may contact the health care provider or facility to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the estimate, ask to negotiate the bill, or ask if financial assistance is available.

• You may also start a dispute resolution process with the U.S. Department of Health & Human Services (HHS).

• If you choose to use the dispute process, you must start it within 120 calendar days of the date on your bill.

• There is a $25 fee to use the dispute process. If the reviewing agency agrees with you, you will only have to pay the amount 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 1-800-985-3059.