GOOD FAITH ESTIMATE NOTICE

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost.

Under federal law, health care providers must give patients who do not have certain types of health care coverage, or who are not using certain types of health care coverage, an estimate of expected charges for health care items and services before those items or services are provided.

•        You have the right to receive a Good Faith Estimate for the total expected cost of health care items or services upon request or when scheduling them. This may include related costs such as medical tests, prescription drugs, equipment, and hospital fees.

•        If you schedule a health care item or service at least 3 business days in advance, you should receive a written Good Faith Estimate within 1 business day after scheduling. If you schedule at least 10 business days in advance, you should receive a written Good Faith Estimate within 3 business days after scheduling.

•        You may also ask for a Good Faith Estimate before scheduling an item or service. If you do, you should receive a written Good Faith Estimate within 3 business days after your request.

•        If you receive a bill from a provider or facility that is at least $400 more than that provider’s or facility’s Good Faith Estimate, you may dispute the bill.

How to Request an Estimate

To request a Good Faith Estimate, contact Dr. Sam Vesuna through the SimplePractice Client Portal or at sam@vesunaMD.com.

More Information

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

Keep a copy of your Good Faith Estimate to compare with bills you receive. The estimate is based on information known at the time and is not a contract for services or a guarantee of final charges.

This notice is adapted from the CMS sample “Notice of Uninsured (or Self-Pay) Individual’s Right to Receive a Good Faith Estimate,” revised August 2023. Final operating procedures, including required oral notice and estimate delivery, should be confirmed for the practice before publication.