You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Click HERE to see the Official CMS-10791 Good Faith Estimate Notice
This practice is a self-pay practice. Under the “No Surprise Act”, health care providers are required to give patients who are not using their insurance or are self-pay, an estimate for the total expected cost over a 12-month period, of any non-emergency items or services.
DISCLAIMERS
The information provided in the Good Faith Estimate is only an estimate and actual services or charges may differ from the Good Faith Estimate.
Additional services, items, or medications may be recommended or required during the course of treatment which are not reflected in the original Good Faith Estimate. Patients must request a separate Good Faith Estimate for these services, items, or medications.
If actual billed charges by the provider during a given year are $400 or more than the estimated or expected charges included in the original Good Faith Estimate, patients have the right to initiate a patient-provider dispute resolution process. This will not adversely affect the quality of care or services provided. To initiate the dispute resolution process, call 801-432-2077. Please make sure to save a copy of your Good Faith Estimate.
If there are changes in the fee schedule, a new Good Faith Estimate can be provided.
A Good Faith Estimate is not a contract and does not require the individual to obtain services from any provider.
For questions about your right to a Good Faith Estimate or to receive or dispute a Good Faith Estimate, call 801-432-2077.
Click HERE to see the Official CMS-10791 Good Faith Estimate Notice
This practice is a self-pay practice. Under the “No Surprise Act”, health care providers are required to give patients who are not using their insurance or are self-pay, an estimate for the total expected cost over a 12-month period, of any non-emergency items or services.
DISCLAIMERS
The information provided in the Good Faith Estimate is only an estimate and actual services or charges may differ from the Good Faith Estimate.
Additional services, items, or medications may be recommended or required during the course of treatment which are not reflected in the original Good Faith Estimate. Patients must request a separate Good Faith Estimate for these services, items, or medications.
If actual billed charges by the provider during a given year are $400 or more than the estimated or expected charges included in the original Good Faith Estimate, patients have the right to initiate a patient-provider dispute resolution process. This will not adversely affect the quality of care or services provided. To initiate the dispute resolution process, call 801-432-2077. Please make sure to save a copy of your Good Faith Estimate.
If there are changes in the fee schedule, a new Good Faith Estimate can be provided.
A Good Faith Estimate is not a contract and does not require the individual to obtain services from any provider.
For questions about your right to a Good Faith Estimate or to receive or dispute a Good Faith Estimate, call 801-432-2077.