Good Faith Estimate

Your Rights Under the No Surprises Act

Effective January 1, 2022, the No Surprises Act (Public Law 116-260) provides federal protections against surprise medical billing. Under this law, you have the right to receive a Good Faith Estimate of expected charges for scheduled healthcare services. This right applies to all patients, including those who are uninsured, self-pay, or choose not to use their insurance benefits. Angeles Medical Clinic is committed to price transparency and helping you understand the cost of your care before you receive it.

What Is a Good Faith Estimate

A Good Faith Estimate is a written notification that provides an estimate of the expected charges for healthcare items and services. This estimate is based on the information known at the time of scheduling and is intended to help you plan for the cost of your care. It is important to understand that a Good Faith Estimate is not a contract or a guarantee of actual charges. The actual charges may vary depending on the services ultimately provided during your visit.

When You Can Expect a Good Faith Estimate

You can receive a Good Faith Estimate in the following situations:

• Upon Scheduling: When you schedule a healthcare service at least 3 business days in advance, we will provide a Good Faith Estimate within 1 business day of scheduling
• Upon Scheduling (10+ days ahead): When you schedule a service at least 10 business days in advance, we will provide the estimate within 3 business days of scheduling
• Upon Request: You may request a Good Faith Estimate at any time before receiving services. We will provide the estimate within 3 business days of your request
• Walk-In Patients: For walk-in visits, we will provide an estimate of expected charges upon request before services are rendered, to the extent practicable

What the Estimate Includes

Your Good Faith Estimate will include the following information:

• Patient name and date of birth
• Description of the primary healthcare item or service being scheduled
• Itemized list of expected charges for each service, item, or procedure
• The expected charges for any related services that are reasonably expected to be provided together with the primary service (such as lab work or diagnostic imaging)
• Healthcare provider name, National Provider Identifier (NPI), and Tax Identification Number (TIN)
• The location where the services will be provided
• Any applicable diagnosis codes
• A disclaimer noting that actual charges may differ from the estimate

If Your Bill Is Higher Than the Estimate

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill. Key points to remember:

• The $400 threshold applies to the total billed charges compared to the total estimated charges on the Good Faith Estimate
• You must initiate the dispute within 120 calendar days of the date on the bill
• You should keep a copy of your Good Faith Estimate for your records
• The dispute resolution process is available at no cost to you, though you may choose to hire a representative at your own expense

How to Dispute a Bill

If you wish to dispute a bill that exceeds your Good Faith Estimate by $400 or more, you can initiate the patient-provider dispute resolution process:

• Step 1: Contact our billing department to attempt to resolve the dispute directly. We are committed to working with patients to address billing concerns
• Step 2: If the dispute cannot be resolved directly, you may initiate the federal patient-provider dispute resolution process through the Centers for Medicare and Medicaid Services (CMS)
• Step 3: Submit your dispute to CMS at cms.gov/nosurprises or by calling 1-800-985-3059
• Step 4: A Selected Dispute Resolution (SDR) entity will review the dispute and make a determination, typically within 30 business days

Self-Pay and Uninsured Patients

Angeles Medical Clinic is committed to providing affordable healthcare to all patients, including those who are uninsured or choose to self-pay:

• Affordable Self-Pay Rates: We offer competitive self-pay rates for all of our services. Our front desk staff can provide pricing information upon request
• Payment Plans: We understand that medical expenses can be a burden. We offer flexible payment plan options to help you manage the cost of your care
• Price Transparency: We are committed to upfront pricing. You are encouraged to ask about the cost of services before your visit
• Financial Assistance: For patients experiencing financial hardship, we may offer discounted rates. Please speak with our billing department to learn about available options

Important Disclaimers

Please keep the following in mind regarding Good Faith Estimates:

• A Good Faith Estimate is not a contract and does not obligate you to receive the listed services
• Actual charges may differ from the estimate based on the services actually provided, unforeseen medical complications, or additional services determined to be necessary during your visit
• The estimate does not include any costs for services provided by other healthcare providers or facilities
• If you have insurance and choose to use it, your health plan may determine coverage and cost-sharing obligations that differ from the estimate

Keeping Your Estimate

We recommend that you save a copy of your Good Faith Estimate for your records. If you receive a bill that is significantly higher than the estimate, having your copy readily available will be important if you choose to dispute the charges. You may request an additional copy of a previously issued estimate at any time by contacting our office.

For More Information

For more information about your rights under the No Surprises Act, visit cms.gov/nosurprises or call 1-800-985-3059. The Centers for Medicare and Medicaid Services provides resources and guidance for patients regarding surprise billing protections and the Good Faith Estimate process.

Contact Us

For billing questions, to request a Good Faith Estimate, or for any concerns regarding your charges, please contact us:

• Email: info@angelesurgentcare.com
• Phone: (213) 457-4000
• Address: 204 E Pico Blvd, Los Angeles, CA 90015