Good Faith Estimate

Your Right to Receive a Good Faith Estimate

You have the right to receive a Good Faith Estimate explaining how much your healthcare services are expected to cost.

Under federal law, healthcare providers must give individuals who do not have certain healthcare coverage, or who are choosing not to use their healthcare coverage, an estimate of the expected charges for healthcare items and services before those services are provided.

When You Should Receive an Estimate

You have the right to receive a Good Faith Estimate when scheduling psychotherapy services or upon request.

• If you schedule a service at least 3 business days in advance, the Practice generally must provide the written estimate within 1 business day after scheduling.
• If you schedule a service at least 10 business days in advance, the Practice generally must provide the written estimate within 3 business days after scheduling.
• You may request a Good Faith Estimate before scheduling services. The Practice generally must provide it in writing within 3 business days after receiving your request.

The estimate will be based on the information known when it is prepared. Actual services or charges may differ if your needs or circumstances change.

If Your Bill Is Higher Than the Estimate

If the bill from a provider or facility is at least $400 more than the amount listed for that provider or facility on your Good Faith Estimate, you may be eligible to dispute the bill through the federal patient-provider dispute-resolution process.

You may first contact the provider to:

• Explain that the billed charges are higher than the estimate
• Ask for the bill to be updated
• Negotiate the bill
• Ask whether financial assistance is available

You may also begin the federal dispute-resolution process within 120 calendar days of the date on the original bill.

Starting a dispute will not adversely affect the quality of healthcare services provided to you. Keep a copy of your Good Faith Estimate and your bill.

Requesting an Estimate

To request a written Good Faith Estimate from Jose H. Caraballo LCSW LLC, contact:

Email: info@josehcaraballolcsw.com
Phone: 786-322-4114
Location: Fort Lauderdale, Florida

Additional Information

For additional information about Good Faith Estimates and the patient-provider dispute-resolution process, visit: cms.gov/nosurprises/consumers

You may also call 1-800-985-3059.

This website notice explains your right to request or receive an estimate. It is not an individualized Good Faith Estimate and does not create a contract for services.