Good Faith Estimate

Notice required under the federal No Surprises Act

What Is a Good Faith Estimate?

If you don't have insurance, or you have insurance but choose not to use it to pay for your care, you have the right to receive a Good Faith Estimate of what your care is expected to cost, before you receive it.

A Good Faith Estimate is a written, itemized breakdown of the services you can reasonably expect to receive, and what each is expected to cost. It's not a bill, and your actual charges may differ from the estimate.

Who This Applies To

This right applies to you if:

• You don't have health insurance, or
• You have health insurance but are choosing to pay for this care yourself rather than file a claim with your plan

What You Can Expect From Us

• If you schedule care at least 3 business days in advance, we'll provide your Good Faith Estimate within 1 business day of scheduling.
• If you schedule at least 10 business days in advance, we'll provide it within 3 business days.
• If you ask for an estimate before scheduling anything, we'll provide it within 3 business days of your request.
• Your estimate will be in writing, in plain language, and will include the expected service, the associated diagnosis and service codes, and the expected charge.

Your Right to Dispute a Bill

If your actual bill is $400 or more above your Good Faith Estimate, you have the right to dispute it. You can:

• Contact us directly to ask us to correct the bill, or to discuss a payment plan or the sliding scale, or
• Start a dispute with the U.S. Department of Health and Human Services, within 120 calendar days of the date on your bill

There is a $25 fee to file a federal dispute, which may be waived in cases of financial hardship. An independent reviewer, not Mercedes Health, decides the outcome, and that decision is binding.

Keep your estimate. Save a copy or take a picture of it. You'll need it if you ever choose to dispute a bill.

Questions About Your Estimate, or About This Notice?

Contact us at 201.281.5936 or info@mercedeshealth.com.

For more information about your rights under federal law, visit cms.gov/nosurprises or call 1-800-985-3059.