Good Faith Estimate Receipt

This form is to confirm you’ve received the updated Good Faith Estimate provided to you.

In the email Kimberleigh sent with the link to this page, you will find a copy of your Good Faith Estimate. The Good Faith Estimate is part of the No Surprises Act law, which gives you the right to receive as estimate of the cost of your treatment when you're not using insurance benefits. The updated estimate you received is for ongoing appointments through the remainder of the calendar year. It is not a contract nor is the total due at once, and with holidays and potential vacations the total amount may be less than the estimated total shown.  The cost estimates provided are based on the same rates from the Financial Agreement you’ve signed.