GOOD FAITH ESTIMATE NOTICE
YOUR RIGHT TO RECEIVE A GOOD FAITH ESTIMATE OF EXPECTED CHARGES
(Required Under the No Surprises Act)
Effective Date: June 17th 2026
WHAT IS A GOOD FAITH ESTIMATE?
Under federal law, healthcare providers are required to provide uninsured patients and self-pay patients with a Good Faith Estimate of expected healthcare charges before services are provided.
A Good Faith Estimate helps you understand the anticipated costs of your healthcare services and allows you to make informed decisions about your care.
HOLISTIC ORIGIN HER WELLNESS COMPLIANCE
Holistic Origin Her Wellness complies with the No Surprises Act and applicable federal requirements regarding Good Faith Estimates for uninsured and self-pay patients.
Patients have the right to receive a written estimate of expected charges before healthcare services are rendered.
WHO IS ELIGIBLE TO RECEIVE A GOOD FAITH ESTIMATE?
You may request a Good Faith Estimate if you:
Patients using insurance may still request pricing information; however, actual insurance responsibility may vary based upon benefits, deductibles, co-insurance, co-payments, network status, and claim adjudication.
SERVICES COVERED
Good Faith Estimates may include anticipated charges for:
The estimate may also identify services that may result in additional charges when known.
LIMITATIONS OF GOOD FAITH ESTIMATES
A Good Faith Estimate is not a contract.
Actual healthcare needs may change after clinical evaluation.
Additional services, referrals, laboratory testing, diagnostic studies, medications, specialist consultations, or other medically necessary services may result in charges not included in the original estimate.
The Good Faith Estimate represents a reasonable estimate based upon information available at the time it is prepared.
CURRENT SELF-PAY FEES
Initial Consultation (30 Minutes)
$150
Follow-Up Visit (15 Minutes)
$75
Membership Program
$169 per month
Minimum initial commitment: 3 months
Continues month-to-month thereafter unless canceled before the next billing cycle.
ADDITIONAL COSTS NOT INCLUDED
The following may result in additional charges and are not typically included in the practice’s Good Faith Estimate:
HOW TO REQUEST A GOOD FAITH ESTIMATE
Patients may request a Good Faith Estimate:
The practice will provide the estimate within applicable federal timeframes.
PATIENT RIGHTS
If you receive a bill that is substantially higher than your Good Faith Estimate, you may have the right to dispute the charges through the federal patient-provider dispute resolution process.
Additional information regarding patient rights under the No Surprises Act is available through the Centers for Medicare & Medicaid Services (CMS).
NO SURPRISES ACT DISCLOSURE
You have the right to receive a Good Faith Estimate explaining how much your healthcare services will cost.
Under federal law, healthcare providers must provide uninsured and self-pay patients with a Good Faith Estimate of expected charges before services are provided.
You may ask your healthcare provider for a Good Faith Estimate before scheduling a service or at any time prior to receiving care.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you may have the right to dispute the bill.
Keep a copy of your Good Faith Estimate for your records.
CONTACT INFORMATION
Holistic Origin Her Wellness
Email: info@holisticoriginherwellness.com
Website: www.holisticoriginherwellness.com
Questions regarding Good Faith Estimates may be directed to the practice using the contact information above.