Good Faith Estimate
Instructions
In the Public Health Service Act, under Section 2799B-6, healthcare facilities and healthcare providers are required to provide a good faith estimate, both orally and in writing, of expected charges for items and services to individuals who are not enrolled in a plan or coverage or a Federal healthcare program, or not seeking to file a claim with their plan or coverage, upon request or at the time of scheduling healthcare items and services.
The information below represents the disclosures required by law. A good faith estimate is based on the most common diagnoses seen within Lion and Lamb Wellness and the total expected charges for the maximum number of sessions allotted within a calendar year. It is possible that your total out-of-pocket costs will be less than this amount. Please discuss with your provider regarding the anticipated length of treatment. Most sessions within Lion and Lamb Wellness are completed between a range of 40-52 visits on average, though your length of treatment will be decided by you and your provider. The good faith estimate is subject to change as treatment progresses. An updated good faith estimate will be provided as needed during the progression of treatment.
Your Good Faith Estimate shows the costs of items and services that are reasonably expected for your healthcare needs for an item or service. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. If you are billed for $400 more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact the healthcare provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (approximately 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the healthcare provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to cms.gov/nosurprises or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit cms.gov/nosurprises or call 1-800-985-3059.
Keep a copy of your Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.