Patient Estimates
Disclaimer
This is a Good Faith Estimate based upon what we currently charge for each item or service that we expect you will need to receive during your scheduled healthcare services. The dollar amounts listed are only estimates. Actual charges for items or services provided to you may vary based on medical condition, unknown circumstances or complications, diagnosis, and recommended treatments ordered by the provider. There may be additional items or services that your provider orders as part of your care that must be scheduled or requested separately. Those items and services are not included in this Good Faith Estimate. You may receive a bill from any other provider participating in this care delivery. If insurance was provided to us to obtain a patient out of pocket estimate, the estimate is then based on benefits provided by the insurance company. Any changes to your coverage or inaccuracies in the information provided by you or the insurance company could result in a difference in actual out of pocket amounts. The estimate is based on information provided at the time it was created, including your prospective insurance coverage. It is recommended you contact your health insurance company to verify that the selected hospital or provider is in-network for the services to be provided, as out of network benefits may result in higher out of pocket costs. For uninsured/Self-Pay patients only, you are being provided a cost estimate either because you requested one, or because a federal mandate requires it. This estimate is based on the information currently available in the billing system we use. If you have health insurance that isn’t reflected in this estimate, please bring your insurance card and/or proof of coverage to your scheduled visit. There may be additional costs related to this service that aren’t included in this estimate. Items such as pre-procedure testing or post-procedure follow-up appointments aren’t included, as they have separate service dates from the visit/procedure included in this estimate. If you want estimates for any other currently scheduled visits or services, you may connect with us using the contact information included in this letter. If the balance owing creates a financial hardship for any reason, please contact us for more information about financial assistance programs to see if you may qualify. You could be charged more if complications or special circumstances occur, because additional items or services that are not included in this Good Faith Estimate may be needed for your treatment. If this happens, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute (appeal) the bill.