Good Faith Estimate Notice

Under the federal No Surprises Act, healthcare providers are required to provide patients who are uninsured or not using insurance with a Good Faith Estimate of expected charges for medical services. This notice explains your rights.

Your Right to a Good Faith Estimate

If you are uninsured or choose not to use insurance, you have the right to receive a written Good Faith Estimate explaining the expected cost of your care.

You may request a Good Faith Estimate before scheduling a service or at any time during treatment.

The Good Faith Estimate will include:

• The expected cost of scheduled services
• The cost of any related services reasonably expected as part of treatment

The estimate will be provided in writing at least 1 business day before a scheduled service when required by law.

What the Estimate Covers

The Good Faith Estimate is based on information known at the time it is created.

It does not include:

• Unexpected services that may arise during treatment
• Emergency services
• Services provided by other healthcare providers

Actual charges may vary depending on your clinical needs.

Dispute Process

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 initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS) within 120 days of receiving the bill.

Information about the dispute process is available at:
www.cms.gov/nosurprises

Questions

If you have questions about your right to a Good Faith Estimate, contact:

Lavender Integrative Psychiatry
Elizabeth Rose Lavender | PMHNP, AGNP
Email: info@lavenderintegrativepsychiatry.com
Website: www.lavenderintegrativepsychiatry.com
Phone: 774-209-2291