Anne Metz LLC

Your Right to a Good Faith Estimate

Anne Metz LLC · annemetz.com · 434-531-2396 · anne@annemetz.com

This notice follows the federal model notice under the No Surprises Act (Public Health Service Act section 2799B-6).

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

Under the law, health care providers must give patients who do not have insurance, or who are not using insurance, an estimate of the expected charges 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.
• If you schedule an item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule at least 10 business days in advance, the estimate is due within 3 business days after scheduling.
• You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
• If you receive a bill that is at least $400 more for any provider or facility than that provider's or facility's Good Faith Estimate, you can dispute the bill. You generally must start the dispute process within 120 calendar days of the date on the original bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

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

How this works at Anne Metz LLC

If you are paying for counseling yourself, or you have insurance but do not plan to use it, you can ask me for a written Good Faith Estimate before you book or at any time afterward. I will also provide one when the law requires it, within the timelines above. The estimate lists the services I expect to provide, my fee for each, and the total for the period it covers. It is an estimate, not a contract: you are not required to receive the services listed, and your needs may change what is billed.

To request an estimate, or for help with an estimate or a billing question, contact me at anne@annemetz.com or 434-531-2396. I can provide the estimate in an accessible format on request.

If you dispute a bill through the federal patient-provider dispute resolution process, I will not send the disputed amount to collections, charge late fees on it, or treat you differently for using that process while the dispute is open.

If you are using New Mexico Medicaid or another health plan for your care, the Good Faith Estimate requirement does not apply to services billed to that plan; your plan's explanation of benefits describes your costs.