Good Faith Estimate of Costs – No Surprises Act

Under federal law (the No Surprises Act), you have the right to receive a Good Faith Estimate of the expected cost of your child’s health care services if you are self-pay or your insurance may not cover all charges.

A Good Faith Estimate is a written statement showing the expected charges for services that are reasonably anticipated for your child’s care. The estimate includes all expected professional fees and other items or services that may be billed. The actual cost may vary depending on your child’s needs and progress. Estimates may be updated at any time if your child’s plan of care or rate of progress changes.

You have the right to:

• Request a Good Faith Estimate before your first appointment or at any time.

• Receive updates to the estimate if your child’s care changes.

• Dispute charges if you are billed more than $400 above your Good Faith Estimate through the federal patient-provider dispute resolution process.

This Good Faith Estimate is not a contract and does not obligate you to receive care. For more information about your rights under the No Surprises Act, visit www.cms.gov/nosurprises.