YOUR RIGHT TO RECEIVE A GOOD FAITH ESTIMATE
Under the federal No Surprises Act, health-care providers generally must provide individuals who do not have insurance or who are not using insurance to pay for their care with an estimate of the expected charges for scheduled services.
This is called a “Good Faith Estimate.”
WHO MAY RECEIVE A GOOD FAITH ESTIMATE
You generally have the right to receive a Good Faith Estimate if:
* You do not have health insurance; or
* You have health insurance but do not plan to submit a claim or use your insurance to pay for the service.
A Good Faith Estimate may also be requested before you decide whether to schedule a service.
WHAT THE ESTIMATE INCLUDES
The Good Faith Estimate will explain the reasonably expected charges for the health-care services to be provided by Sharon Lemire Therapeutic Services, based on the information known when the estimate is prepared.
The estimate is not a contract and does not require you to receive services from this practice.
The estimate may not include unexpected services or costs that could become necessary during treatment. If the scope, frequency, duration, or anticipated cost of services changes, an updated estimate may be provided as required or appropriate.
WHEN YOU WILL RECEIVE THE ESTIMATE
If you schedule a service between 3 and 9 business days in advance, the Good Faith Estimate will generally be provided within 1 business day after scheduling.
If you schedule a service at least 10 business days in advance, the Good Faith Estimate will generally be provided within 3 business days after scheduling.
If you request a Good Faith Estimate before scheduling a service, it will generally be provided within 3 business days after the request.
A Good Faith Estimate is generally not required when a service is scheduled fewer than 3 business days in advance, although you may still ask about the expected cost of services.
The estimate will be provided in writing, either electronically or on paper, according to your requested or agreed method of communication.
DISPUTING A BILL
If you receive a bill from a provider that is at least $400 more than that provider’s Good Faith Estimate, you may be eligible to use the federal patient-provider dispute-resolution process.
Keep a copy or photograph of your Good Faith Estimate and any bills you receive.
Beginning a dispute will not adversely affect the quality of services you receive from this practice.
QUESTIONS OR REQUESTS
To request a Good Faith Estimate or ask questions about expected charges, contact:
Sharon Lemire, DSW, LCSW
Sharon Lemire Therapeutic Services
Telephone: (323) 880-7971
Email: [Sharon@sharonlemirelcsw.com](mailto:Sharon@sharonlemirelcsw.com)
You may also obtain information about Good Faith Estimates and the patient-provider dispute-resolution process from the Centers for Medicare & Medicaid Services:
Website: www.cms.gov/nosurprises/consumers
Telephone: 1-800-985-3059
Email: FederalPPDRQuestions@cms.hhs.gov
This notice explains your federal right to receive a Good Faith Estimate. It is not itself an individualized estimate of the anticipated charges for your treatment.