Your Right to a Good Faith Estimate

You may generally qualify when you do not have health insurance or when you have coverage but do not plan to submit a claim or use that coverage for the scheduled service.

• Tell the practice before the service that you do not plan to use insurance.
• Request cost information before deciding whether to schedule care.
• Ask for the estimate in paper or electronic form.

Emergency care: Good Faith Estimate procedures are generally intended for care arranged in advance and do not require delaying emergency or urgently needed care.

The timing generally depends on how far in advance the service is scheduled or whether you request an estimate before scheduling.

When care is scheduled fewer than three business days in advance, federal rules generally do not require a Good Faith Estimate, although available cost information may still be provided.

A written estimate may identify the patient, scheduled service, expected date or date range, provider or facility and the expected charges for the reasonably anticipated items and services.

• An itemized description of expected services.
• The expected charge for each listed item or service.
• Applicable service or diagnosis codes when required.
• The provider or facility issuing the estimate.
• Disclaimers about additional or unexpected services.
• Information about possible billing-dispute rights.

The estimate is based on the information reasonably known when it is prepared. It does not require a provider to predict every possible clinical development.

Current self-pay charges should be confirmed through the practice’s approved scheduling or estimate-request process. The amount may depend on the service, anticipated appointment length, number of expected visits and other information known when the estimate is prepared.

The written estimate controls: General website cost information does not replace the individualized Good Faith Estimate prepared for the specific scheduled course of care.

An estimate from A to Z Psychiatry and Wellness PLLC may cover only the items and services expected to be provided and billed by this practice. Another provider or organization may issue a separate bill.

• Laboratory, pharmacy or medication costs.
• Imaging, diagnostic or psychological testing.
• Emergency, hospital or facility services.
• Another clinician, specialist or outside provider.
• Outside records, platforms or administrative services.

Request a separate estimate directly from each additional provider or facility that may bill for its own services.

Final charges may differ when the scheduled service, appointment length, expected number of visits or course of care changes, when unexpected clinical needs arise or when another provider or facility becomes involved.

• A different service or level of care is provided.
• Additional visits are requested or recommended.
• New information changes the anticipated care plan.
• A visit is cancelled, rescheduled, missed or extended.

A revised estimate may be issued when a material change becomes known before the applicable care is provided.

A federal patient-provider dispute-resolution process may be available when the bill from a provider or facility is at least $400 more than the corresponding expected charges shown on that provider’s or facility’s Good Faith Estimate.

You may first contact the practice to ask whether a billing error occurred or whether the difference can be explained. Contacting the practice does not extend a federal filing deadline.

Review current eligibility and filing instructions through the official CMS medical-bill-rights website .

Contact the practice when you need to:

• Request a written Good Faith Estimate.
• Obtain another copy of an estimate.
• Correct the service or date listed.
• Ask for an explanation of a practice bill.
• Report a payment or account-posting concern.

A federal complaint may also be available when a person believes an estimate should have been provided but was not. Filing a complaint does not itself cancel the bill or replace a separate billing-dispute process.

This page is not:

• An individualized Good Faith Estimate.
• A guarantee of final charges.
• A promise that every possible service is listed.
• A determination of dispute eligibility.
• Legal, tax, financial or insurance advice.

Requirements may change. The practice may revise this page when its services, rates, billing procedures or applicable requirements change.

Do not delay urgent care: Seek appropriate emergency or urgent assistance without waiting for an estimate.

Contact A to Z Psychiatry and Wellness PLLC before receiving self-pay care. Identify the service you are considering or have scheduled, the expected date or date range and your preferred delivery method.

Avoid sending Social Security numbers, payment-card details, portal passwords, verification codes or unnecessary clinical information in the initial request.