Good Faith Estimate

Your Right to a Good Faith Estimate

Under the No Surprises Act (effective January 1, 2022), you have the right to receive a Good Faith Estimate of expected charges before you receive services. This right applies to uninsured clients and to insured clients who choose not to use their insurance benefits.

A Good Faith Estimate is not a contract and does not require you to obtain services at The Healing Suite.

Standard Service Fees

The following are our current standard fees for services. Your Good Faith Estimate will reflect the specific services expected for your care.

Fees are subject to change. Your personalized Good Faith Estimate will reflect the specific services planned for your care at the time it is issued.

What Is Included in a Good Faith Estimate

Your Good Faith Estimate will include:

• —A description of the services expected
• —An itemized list of items or services reasonably expected for your treatment
• —Expected charges for each item or service
• —Diagnosis and service codes (if applicable)
• —Name and contact information of the provider

Scheduling and Timing

If you schedule a service at least three business days in advance, you will receive a Good Faith Estimate no later than one business day before your appointment. If you schedule at least ten business days in advance, you will receive it no later than three business days before your appointment.

You may also request a Good Faith Estimate at any time, even before scheduling a specific appointment.

Dispute Resolution

If you receive a bill that is at least $400 more than your Good Faith Estimate, you may dispute the bill. To do so:

• —Save a copy of your Good Faith Estimate
• —Contact us directly to discuss any discrepancies
• —You may initiate the dispute resolution process through the U.S. Department of Health and Human Services within 120 calendar days of the date on your bill

More information about the dispute resolution process is available at cms.gov/nosurprises.

Insurance

The Healing Suite is currently an out-of-network provider for all insurance plans. We do not bill insurance directly. Upon request, we can provide a superbill that you may submit to your insurance company for potential reimbursement, depending on your plan's out-of-network benefits.

Your Good Faith Estimate does not account for any potential reimbursement from your insurance company.

Request a Good Faith Estimate

To request a personalized Good Faith Estimate before scheduling, contact us at: