Good Faith Estimate & No Surprises Act

Under the federal No Surprises Act (Section 2799B-6 of the Public Health Service Act), health care providers and health care facilities are required to inform individuals who are not enrolled in a group health plan or group or individual health insurance coverage, or who are not seeking to file a claim with their plan or coverage, of their right to receive a "Good Faith Estimate" of expected charges.

Your Right to a Good Faith Estimate

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency health care services, including mental health and psychotherapy services.

• For scheduled services, you may request a Good Faith Estimate in writing at least 1 business day before your scheduled service.
• For services requested without scheduling, we will provide a Good Faith Estimate within 3 business days of scheduling (or 1 business day if scheduled less than 3 business days in advance).
• If you schedule services at least 3 business days in advance, we will provide a Good Faith Estimate within 1 business day of scheduling.
• You may also request a Good Faith Estimate before scheduling any services.

What the Estimate Includes

The Good Faith Estimate will include the expected charges for the scheduled service or items, including the diagnosis and service codes, the expected charge for each service, and any other expected charges. The estimate is not a contract and does not obligate you to obtain services from us.

If Your Bill Is Higher Than the Estimate

If you receive a bill that is at least $400 more than your Good Faith Estimate, you may dispute the bill under the No Surprises Act. To dispute a bill:

• You must initiate the dispute within 120 calendar days of the date on the original bill
• You must include a copy of the Good Faith Estimate, the original bill, and an explanation of why you believe the bill is higher than expected
• We will have 30 days to respond and either negotiate a settlement or provide a written explanation of why the bill is accurate

For more information about your rights under the No Surprises Act, visit www.cms.gov/nosurprisesor call 1-800-985-3059.

How to Request a Good Faith Estimate

To request a Good Faith Estimate, contact us at:

SOULFLO Therapy
7290 Navajo Road #105, San Diego, CA 92119
(619) 292-8885
nancy@soulflotherapy.com

Note: The Good Faith Estimate applies to self-pay clients and those not using insurance. If you are using insurance, your actual costs will depend on your plan's benefits, copayments, deductibles, and coinsurance. Please contact your insurance provider for details about your coverage.