Good Faith Estimate
Under 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 plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing, of their ability, upon request, or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.
This form may be used by the health care providers to inform individuals who are not enrolled in a plan or coverage or a Federal Health care program (uninsured individuals) or individuals who are enrolled but not seeking to file a claim with their plan or coverage, (self-pay individuals) of their right to a “Good Faith Estimate” to help them estimate the expected charges they may be billed for receiving certain health care items and services. Frame of Mind, LLC, will provide you with a “Good Faith Estimate” both verbally and in writing upon scheduling of therapy services. Thank you.