Good Faith Estimate

01Your right to a Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

02Who this applies to

This notice applies to you if you are:

• A self-pay patient who does not have health insurance.
• An insured patient who chooses not to bill your insurance for a visit or service.
• A Direct Primary Care (DPC) member. Your membership fee is paid directly to us, so we will give you an estimate that covers your membership and any services billed outside it.

If you are using insurance, your plan’s rules on cost-sharing apply instead. Our team can still help you understand your benefits. See Insurance & Billing.

03When you will receive it

We will send the estimate by your choice of paper or electronic delivery, and we can review it with you by phone.

04What the estimate includes

• Your name and date of birth.
• A description of the service and the date it is scheduled, if known.
• An itemized list of each expected item or service, with service and diagnosis codes and the expected charge.
• Expected charges from other providers or facilities involved in your care, when we are required to include them.
• Any items or services you may need to schedule separately.
• A statement that the estimate is not a contract and that you do not have to receive the service from us.

05If your bill is higher than your estimate

If your bill from us is at least $400 more than your Good Faith Estimate, you can start the federal patient-provider dispute resolution process. You must start within 120 calendar days of the date on the bill. There is a small administrative fee, which is refunded if the decision is in your favor.

Before you start, call us at 903.488.CARE. We would rather fix a billing problem with you directly.

Learn how to file at www.cms.gov/nosurprises or call 1-800-985-3059.

06How to request an estimate

Call 903.488.CARE, ask at the front desk, or email contact@luckycharmprimarycare.com. Tell us the service you are considering and the date, if you know it. Please do not include detailed medical information in email.