Good Faith Estimate Notice
Your Right to Receive a Good Faith Estimate
Under the law, health care providers need to 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 any non-emergency health care items or services upon request or when scheduling services.
A Good Faith Estimate will include the total expected cost of the items and services reasonably expected to be provided by Elements of Wellness Counseling. When applicable, it may also include related costs.
If you schedule a service at least 3 business days in advance, you should receive a Good Faith Estimate in writing within 1 business day after scheduling.
If you schedule a service at least 10 business days in advance, you should receive a Good Faith Estimate in writing within 3 business days after scheduling.
You can also ask for a Good Faith Estimate before you schedule a service. If you do, you should receive it in writing within 3 business days after your request.
If you receive a bill that is at least $400 more than your Good Faith Estimate from this provider, you may have the right to dispute the bill.
Be sure to save a copy or picture of your Good Faith Estimate.
For questions about your right to a Good Faith Estimate, visit the federal No Surprises information page, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.