HOLISTIC ORIGIN HER WELLNESSTM ☐ READ ☐ ASK ☐ SIGN
GOOD FAITH ESTIMATE NOTICE
YOUR RIGHT TO RECEIVE A GOOD FAITH ESTIMATE OF EXPECTED CHARGES
Under the No Surprises Act
Effective Date: ____________________
YOUR RIGHT TO A GOOD FAITH ESTIMATE
A Good Faith Estimate is a written estimate of the expected charges for scheduled healthcare items or services. It is
intended to help you understand anticipated costs before receiving care.
Holistic Origin Her WellnessTM is a cash-pay consultation practice and does not bill insurance for consultation services.
WHO MAY RECEIVE A GOOD FAITH ESTIMATE
You may be eligible to receive a Good Faith Estimate when you:
• Do not have health insurance, or
• Have health insurance but do not plan to use it to pay for the scheduled service.
You may request a Good Faith Estimate before scheduling or before receiving an applicable self-pay healthcare service.
WHEN A GOOD FAITH ESTIMATE IS PROVIDED
Under current federal requirements, a Good Faith Estimate is generally provided when an uninsured or self-pay patient
requests one or schedules an applicable service sufficiently in advance.
• If a service is scheduled 3-9 business days in advance, the estimate generally must be provided within 1 business
day after scheduling.
• If a service is scheduled 10 or more business days in advance, the estimate generally must be provided within 3
business days after scheduling.
• If you request an estimate before scheduling, it generally must be provided within 3 business days after the request.
Federal requirements may not require a Good Faith Estimate when care is scheduled only 0-2 business days in
advance.
CURRENT HOLISTIC ORIGIN HER WELLNESSTM CONSULTATION FEES
Current cash-pay consultation fees are:
• Initial Women’s Health Consultation – 90 minutes: $495
• Follow-Up Consultation for established patients – 45 minutes: $225
The patient-specific Good Faith Estimate provided for a scheduled service will identify the expected charge applicable
to that service. Fees may change prospectively; the estimate issued for a scheduled service should be used when
comparing expected charges with the final bill.
WHAT THE ESTIMATE MAY INCLUDE
A Good Faith Estimate from Holistic Origin Her WellnessTM may include the expected charge for the consultation
service scheduled with the practice and other items or services the practice is required and reasonably able to include
under applicable federal requirements.
The estimate is based on information reasonably available when it is prepared.
OUTSIDE COSTS
Outside providers or facilities may charge separately for their services. A Good Faith Estimate from Holistic Origin Her
WellnessTM generally reflects charges from this practice and may not include separately scheduled services or charges
from another provider or facility.
If you do not have health insurance or you are choosing not to use health insurance to pay for your care, you
generally have the right to receive a Good Faith Estimate of expected charges before scheduled healthcare
services.
Laboratory testing, imaging, medications, specialist care, procedures, urgent care, emergency care, and other
services provided by outside professionals or facilities are not included in the Holistic Origin Her WellnessTM
consultation fee.
Holistic Origin Her WellnessTM | Good Faith Estimate Notice
HOLISTIC ORIGIN HER WELLNESSTM ☐ READ ☐ ASK ☐ SIGN
When you expect to receive services from another provider or facility, you may need to request a separate Good Faith
Estimate from that provider or facility.
LIMITATIONS OF A GOOD FAITH ESTIMATE
A Good Faith Estimate is an estimate and is not a contract.
The estimate reflects services reasonably expected at the time it is prepared. Your healthcare needs or the services you
choose to receive may change.
Additional or separately scheduled services that were not reasonably anticipated may not appear on the original
estimate.
Nothing in a Good Faith Estimate requires you to receive the listed service from Holistic Origin Her WellnessTM.
IF YOUR BILL IS HIGHER THAN YOUR ESTIMATE
Federal eligibility requirements apply. Among other requirements, the dispute generally must be initiated within 120
calendar days of the date on the initial bill.
Keep a copy of your Good Faith Estimate and compare it with your final bill.
HOW TO REQUEST A GOOD FAITH ESTIMATE
You may request a Good Faith Estimate from Holistic Origin Her WellnessTM before scheduling or before receiving an
applicable self-pay consultation.
Requests may be submitted through a practice-approved communication method, including:
• Secure patient portal
• Email
• Website contact method
• Telephone or other approved practice communication method
The practice will provide the estimate within applicable federal timeframes.
QUESTIONS OR BILLING CONCERNS
If you have questions about an estimate or believe a charge from Holistic Origin Her WellnessTM is incorrect, contact the
practice promptly so the concern can be reviewed.
For information about federal Good Faith Estimate rights and the patient-provider dispute resolution process, patients
may also consult the Centers for Medicare & Medicaid Services (CMS) No Surprises resources.
CONTACT INFORMATION
Holistic Origin Her WellnessTM
Email: info@holisticoriginherwellness.com
Website: www.holisticoriginherwellness.com
Questions regarding Good Faith Estimates may be directed to the practice using the contact information above.
PATIENT ACKNOWLEDGMENT
By signing or electronically acknowledging this notice when presented as part of patient onboarding, I acknowledge that
I have received or been offered information regarding my right to receive a Good Faith Estimate of expected charges.
I understand that this notice explains my rights generally and that a patient-specific Good Faith Estimate may be
provided separately for a scheduled or requested service.
Patient Name: _______________________________________________________
Patient Signature: _______________________________________________________
Date: _________________________
If a provider or facility bills you at least $400 more than the amount shown on that provider’s or facility’s Good Faith
Estimate, you may be eligible to use the federal patient-provider dispute resolution process.
Holistic Origin Her WellnessTM | Good Faith Estimate Notice