Your Right to a Good Faith Estimate

Last updated: [LAST UPDATED — to be supplied by the practice]

Who this applies to

Under the federal No Surprises Act, people who are uninsured or who are insured but choose not to use their insurance ("self-pay") have the right to receive a Good Faith Estimate of the expected charges for scheduled care.

What you can expect

• A written estimate of expected charges for evaluations, medication management visits, therapy sessions, TMS treatment courses, or any other service you schedule.
• An estimate automatically when you schedule at least three business days in advance, and any time you ask for one.
• An estimate within one business day of scheduling if the service is at least three business days out, or within three business days if it is at least ten business days out.
• An estimate within three business days of a request, whether or not you schedule.
• An explanation of the estimate in person or by phone if you want one.

What an estimate is and is not

An estimate reflects the services reasonably expected at the time it is written. It is not a contract and does not obligate you to receive the care listed. Your actual charges may differ if your treatment plan changes — for example, if a TMS course is extended or additional visits are needed.

If you are billed more than your estimate

If you receive a bill that is at least $400 more than your Good Faith Estimate, you may dispute the bill through the federal patient-provider dispute resolution process. You must start the process within 120 calendar days of the date on the bill. There is a small administrative fee, and you will not be penalized for disputing a bill.

Learn more at cms.gov/nosurprises or call 1-800-985-3059.

How to request an estimate

Call (502) 454-8800 during office hours, or ask our front desk at 3430 Newburg Road, Suite 210, Louisville. Keep a copy of your estimate for your records.