Good Faith Estimate

Your Right to a Good Faith Estimate

You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

When You Can Request a Good Faith Estimate

You can request a Good Faith Estimate before you schedule a service, or at any time before receiving the service. To request a Good Faith Estimate from Knapp Chiropractic Center, please contact us:

What Is Included in a Good Faith Estimate

A Good Faith Estimate will include:

• Patient name and date of birth
• Description of the primary item or service being provided
• Date the primary item or service is scheduled
• Itemized list of items and services grouped by provider or facility
• Applicable diagnosis codes, expected service codes, and expected charges
• Name, National Provider Identifier (NPI), and Tax Identification Number (TIN) of each provider
• A disclaimer that the Good Faith Estimate is not a contract and actual charges may vary

Disputing a Bill

If you are billed for more than the Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed 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 on 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 the Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

For More Information

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Effective Date: January 1, 2022
Last Updated: January 2025
Provider: Knapp Chiropractic Center, 1384 Vera Dr., Hillsdale, MI 49242