NO SURPRISES ACT – BALANCE BILLING DISCLOSURE NOTICE
PLEASE NOTE THAT A GOOD FAITH ESTIMATE IS AVAILABLE FOR ALL CLIENTS UPON REQUEST FROM THE ADMIN OFFICE. All out-of-network insurance and self-pay clients will receive a GFE as part of the intake process to be signed before the initial appointment.
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact The Renovo Center LLC 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 of 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 Renovo Center LLC, you will have to pay the higher amount.
Visit www.cms.gov/nosurprises for more information about your rights under federal law.
