Your right to receive a Good Faith Estimate
If you do not have health insurance or choose not to use your insurance for care, you generally have the right to receive a written Good Faith Estimate explaining your expected health care costs.
At Cotallat Psychiatry, you may request an estimate before deciding whether to schedule an appointment. You do not need to commit to treatment to receive one.
What your estimate includes
Your Good Faith Estimate outlines the services reasonably expected for your care and their anticipated charges. These may include psychiatric evaluations, medication management, and psychotherapy. For ongoing care, the estimate may include the expected number and frequency of visits over a specified period.
Services billed separately by other providers, such as laboratory testing or prescriptions filled at a pharmacy, may require separate estimates from those providers.
When you will receive your estimate
If you request an estimate before scheduling, we will provide it within 3 business days of your request.
If you schedule care 3 to 9 business days in advance, we will provide your estimate within 1 business day after scheduling. If you schedule care at least 10 business days in advance, we will provide it within 3 business days after scheduling.
Your estimate will be provided in writing, on paper or electronically, according to your preference.
Understanding your estimate
An estimate reflects the information available when it is prepared. Unanticipated needs or changes in your treatment may affect the services provided and their costs. We will provide an updated estimate when required by law.
A Good Faith Estimate is not a contract and does not require you to receive services from our practice. Changes in your care or charges do not remove your right to dispute an eligible bill.
Your right to dispute a bill
If a bill from a provider or facility is $400 or more above the amount estimated for that provider or facility, you may qualify for the federal patient and provider dispute resolution process. A dispute generally must be initiated within 120 calendar days of the date on the initial bill.
You may contact our office with billing questions, but contacting us first is not required to initiate a federal dispute. Keep a copy of your estimate and related bills.
Questions or requests
To request a Good Faith Estimate, contact Cotallat Psychiatry at (917) 410 2064 or admin@cotallat.com. Established patients may also use the secure patient portal.
For more information about your rights or the federal dispute process, visit cms.gov/nosurprises, opens in a new window or call (800) 985 3059.
This notice explains your rights. Your individual Good Faith Estimate will identify the services and charges expected for your care. Nothing in this notice limits your rights under applicable law.