Good Faith Estimate Notice

This Good Faith Estimate notice is a draft and requires attorney review. It is not the practice's final legal notice.

Under the No Surprises Act, health care providers generally must give patients who do not have insurance, or who are not using insurance for an item or service, an estimate of the expected charges for scheduled or requested non-emergency care.

If you are uninsured or plan to self-pay, you have the right to receive a Good Faith Estimate explaining how much your care is expected to cost. The estimate may include reasonably expected items or services associated with the scheduled care.

If you schedule care at least 10 business days in advance, a Good Faith Estimate generally must be provided within 3 business days after scheduling. If you schedule at least 3 business days in advance, it generally must be provided within 1 business day after scheduling. You may also request an estimate before scheduling, and one generally must be provided within 3 business days after the request.

Make sure you receive a written or electronic copy of your Good Faith Estimate at least 1 business day before scheduled care when the timing rules apply. Keep a copy for your records.

A Good Faith Estimate is based on information known when it is prepared and is not a contract or guarantee of the final charges. It may not include unexpected items or services that become reasonably necessary during care. Separate providers or facilities may issue their own estimates.

You may ask questions about the estimate or request an updated estimate if the recommended services or expected charges change.

If a provider bills you at least $400 more than that provider's Good Faith Estimate, you may be eligible to use the federal patient-provider dispute resolution process. Starting a dispute will not adversely affect the quality of health care services provided to you.

For information about Good Faith Estimates and the dispute process, visit cms.gov/nosurprises or call the federal No Surprises Help Desk at 1-800-985-3059. Deadlines and administrative fees may apply, so review current federal guidance promptly.

To request a Good Faith Estimate or ask a billing question, call our Rancho Cucamonga office at (909) 345-6100 or our Chino office at (909) 345-9809. Please tell us that you are uninsured or do not plan to submit the scheduled care to insurance.