Fees and Insurance

Under the federal No Surprises Act, I am required to inform of the following rights you have regarding advance notice of the out of pocket costs you may incur if you are uninsured, or if you have non-governmental health insurance coverage.

Upon the scheduling of any non-emergency encounter, or upon your request, we will disclose whether we participate in your health insurance plan.

Should we be unable to quote a specific amount due the inability to predict in advance your specific treatment needs or diagnosis, we will disclose an estimate of the out of pocket costs you will be required to pay.

If we do not participate in your health insurance plan, or if you choose not to use your health insurance for care rendered by our practice, or if you are uninsured, you have a right to receive a written disclosure of the charges you will be responsible to pay us which will be provided to you via a written Good Faith Estimate of your expected out of pocket health care costs within the following time frames:

• If you schedule your appointment at least 10 business days in advance: within 3 business days after scheduling.
• If you schedule your appointment at least 3 business days in advance: within 1 business day after scheduling.

You also have the right to request a Good Faith Estimate in writing within 3 business days of request, even if your visit will be covered by your non-governmental health insurance plan. If we are unable to tell you a specific amount (because we cannot predict what specific treatment will be needed), we will disclose to you the estimated maximum amount that you will pay.

You have a right to dispute a bill from our office if it is at least $400 more than the Good Faith Estimate we have provided you. For any questions or more information about your rights under the No Surprises Act, visit www.cms.gov/nosurprises/consumers. or call 1- 800-985-3059.