Right to Receive a Good Faith Estimate

Under section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are self-paying for a medical service a Good Faith Estimate, or estimate of the cost of your health care services. If you receive a bill of at least $400 more than your Good Faith Estimate, you can dispute the bill. Health care facilities are required to include the following information in your Good Faith Estimate:

• Client’s name
• Client’s date of birth
• Diagnosis codes
• Payment method
• Provider name
• Provider’s National Provider Identifier
• Company’s National Provider Id
• Tax ID number
• Location of services
• Estimated cost of services
• Client signature and date of signature
• List of treatment codes that may be charged
• Cost of each treatment code that may be charged
• Notice that the client is not obligated or required to obtain any of the listed services from the provider
  

Revision Health Services provides all self-pay clients with a Good Faith Estimate. These are scanned into each client’s electronic chart and the hard copy is left with each client.