Good Faith Estimate

1. Your Right to a Good Faith Estimate

Under the federal No Surprises Act, you have the right to receive a Good Faith Estimate explaining how much your medical care will cost.

Healthcare providers must give patients who do not have insurance, or who are not using insurance, an estimate of the expected charges for medical services, items, and procedures.

This applies to every Holy City Med patient. We do not take insurance or Medicaid, so every one of our patients is a self-pay patient with this right.

2. What You Are Entitled To

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services
• You can ask any healthcare provider or facility for a Good Faith Estimate before you schedule an item or service
• If you schedule an item or service at least three business days in advance, you must be given a Good Faith Estimate in writing within one business day of scheduling
• If you schedule at least ten business days in advance, you must be given it within three business days
• If you simply ask for an estimate, you must be given one in writing within three business days
• You have the right to receive it in a format you can access, and in your preferred language where possible

3. How to Request One

Ask any member of our team at either clinic, call us on 843-465-9248, or email [email protected]. Make sure to save a copy of the estimate you receive.

Because we publish our prices, you can also see most of our costs before you contact us at all — our full price list is at holycitymed.com/pricing.

4. If Your Bill Is More Than Your Estimate

If you are billed for $400 or more above your Good Faith Estimate, you can dispute the bill.

You may start a patient-provider dispute resolution process with the U.S. Department of Health and Human Services. You must start the dispute process within 120 calendar days of the date on the original bill. There is a $25 administrative fee to use the dispute process.

If the dispute resolution entity agrees with you, you will pay the price on the Good Faith Estimate. If it agrees with the provider, you will pay the higher amount.

5. What an Estimate Does and Does Not Cover

A Good Faith Estimate shows the costs of items and services that are reasonably expected for your care. If something unexpected comes up during your visit — a condition we did not know about, or a test that turns out to be needed — the estimate will not include it. It is an estimate, not a contract, and it does not oblige you to receive any of the items or services listed.

6. More Information

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

7. Contact Us

To request a Good Faith Estimate or ask a question about one you have received: