GOOD FAITH ESTIMATE

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

Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage (“Uninsured/Self-Pay Patients”) an estimate of their bill for health care items and services before those items or services are provided.

• If you are an Uninsured or Self-Pay Patient, you have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask. If your bill for expected costs is $400 or more for any provider than your GFE for that provider, federal law allows you to dispute the bill.

• This GFE does not include any unknown or unexpected costs that may arise during treatment. Unique to Dermatology, you may schedule your appointment for a particular reason and during your visit you or the provider may identify other areas of concern and the provider may perform unexpected procedures which were not contemplated at the time this GFE was created (such as a biopsy which would also result in unanticipated charges for pathology services). You could be charged more if complications or circumstances previously described occur.