Good Faith Estimate for Patients with a Sliding Fee Scale

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You have been sent a Text with the expected co-pay for your upcoming visit.  The quoted price applies to the following (but is not limited to) visit types:

• Physicals
  • 9382, 99384, 99385, 99386, 99383, 99381, 99394, 99395, 99396, 99397, 99392, 99393, 99391
• Medical Follow-ups
  • 99212, 99213, 99214, 99202, 99203, 99205
• Acute Care (Sick Visits) (CPT Codes)
  • 99212, 99213, 99214, 99202, 99203, 99205

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These visits include the examination by a medical provider, limited general health screenings, standard lab tests, and in-house lab tests. If during this appointment it is determined that you need a lab or other service that is not covered by your co-pay (Extended Service), you will be informed of the need and the cost to you before that service is performed

 

Extended Services/Prompt Pay Incentive: Non-standard medical procedures and non-standard lab tests are not included in the visit co-pay.  A prompt pay incentive of a 40% reduction from the full price is available when these Extended Services are provided and paid in full at the time of the appointment.

 

Immunizations: You may qualify for vaccines through the Texas Vaccine for Children (TVFC) or Adult Safety Net (ASN), these programs provide the vaccine at no cost, however, you will be billed an administration fee of $14.95 per vaccine administered   Should you not qualify for TVFC/ASN or need a vaccine not covered by these programs, you will be offered the vaccine at standard cost and will be eligible for

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Disclaimer: 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 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

 

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 health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

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