GOOD FAITH ESTIMATE
A good faith estimate shows the cost of items and services that are reasonably expected for your healthcare needs for an item of service at Dirne Health Centers, Inc. (also known as “Heritage Health”).
This estimate is based on our understanding of your needs today. While caring for you, our providers may recommend additional services not listed here, or unknown or unexpected costs may arise during your service. Because of this, your final charges may differ from the estimate set forth in this document.
Payment for services will depend on your income. Heritage Health offers fee discounts based on your income and the number of people in your household. Heritage Health will help you determine your payment group.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care 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 (about 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 health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.