Effective Date: January 1, 2025

Your Right to a Good Faith Estimate

Under the No Surprises Act (effective January 1, 2022), healthcare providers are required to give patients who are uninsured or who are not using insurance an estimate of expected charges for services.

What Is a Good Faith Estimate?

A Good Faith Estimate is a written notification that outlines the expected charges for scheduled or requested healthcare services. The estimate is based on the information available to the provider at the time the estimate is prepared.

Who Receives a Good Faith Estimate?

You have the right to receive a Good Faith Estimate if you:

• Do not have health insurance coverage
• Are not planning to submit a claim to your insurance for the services
• Request an estimate of charges

When Will You Receive a Good Faith Estimate?

If you schedule a service at least 3 business days in advance, Riverstone Chiropractic will provide you with a Good Faith Estimate within 1 business day after scheduling. If you schedule a service at least 10 business days in advance, the estimate will be provided within 3 business days after scheduling. You may also request a Good Faith Estimate at any time before receiving care.

What Is Included?

The Good Faith Estimate will include:

• Your name and date of birth
• A description of the primary service or item being scheduled or requested
• An itemized list of each item or service reasonably expected to be provided
• The expected charges associated with each listed item or service
• The applicable diagnosis codes
• The name, National Provider Identifier (NPI), and Tax Identification Number (TIN) of the provider

Your Rights Under the No Surprises Act

A Good Faith Estimate is not a contract and does not require you to obtain the services listed. You are not obligated to receive care from Riverstone Chiropractic based on the estimate.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you may dispute the bill through the Patient-Provider Dispute Resolution process. You can learn more and find instructions at cms.gov/nosurprises.

Questions?

If you have questions about your right to a Good Faith Estimate or would like to request one, please contact our office:

Riverstone Chiropractic
Phone:
Email:

For more information about your rights under the No Surprises Act, visit cms.gov/nosurprises.