Full Good Faith Estimate Notice

NOTICE OF RIGHT TO RECEIVE A GOOD FAITH ESTIMATE OF EXPECTED CHARGES

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

Under federal law, healthcare providers must give patients who do not have insurance or who are not using insurance to pay for their care an estimate of expected charges for healthcare items and services.

You have the right to receive a Good Faith Estimate for the expected cost of non-emergency healthcare items and services provided by the Practice. You can ask the Practice for a Good Faith Estimate before you schedule an item or service.

If you schedule a service 3 to 9 business days in advance, the Practice will provide a written Good Faith Estimate within 1 business day after scheduling. If you schedule a service 10 or more business days in advance, the Practice will provide a written estimate within 3 business days after scheduling. If you request a Good Faith Estimate before scheduling, the Practice will provide a written estimate within 3 business days after your request.

Federal law requires the Practice to tell you about your right to receive a Good Faith Estimate, orally and in writing, when you schedule services and when you ask about the cost of services.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you may be eligible to dispute the bill. Save a copy or photograph of your Good Faith Estimate and compare it with your bill. You must initiate the dispute within 120 calendar days of receiving the initial bill.

To request a Good Faith Estimate, contact: Telephone: (914) 614-8427 Email: info@cutlerpediatric.com. You may ask for your Good Faith Estimate to be explained by telephone or in person and may request the estimate in an accessible format or a language you speak.

For questions or more information about your rights concerning Good Faith Estimates, visit www.cms.gov/nosurprises or call 1-800-985-3059.