Eastern Iowa Psychiatric Services PC Disclaimer

Good Faith Estimate Disclaimer

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that is not in your health plan's network. This Good Faith Estimate (GFE) shows the costs of services that are reasonably expected for your health care needs. 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. Refer to the Welcome Packet document for potential "out of session" costs including a $50 no show fee, disability paperwork, any court-related services, etc. These "out of session" costs cannot be pre-determined and are therefore

not included in this GFE. You are responsible for charges related to special circumstances that may change the above-identified estimate.

Federal law regarding the "No Surprises Act" allows you to dispute the bill if it is different than the above-identified estimate. You may contact the health care provider and/or facility listed above to let them know that the billed charges are higher than the GFE. You have the following rights:

1. ask them to amend the charges to match the GFE;
2. ask to negotiate the bill and/or ask if financial assistance is available;                          
3. dispute the resolution process with the U.S. Department of Health and Human Services (HSS).

If you choose to dispute the billed charges, you must begin your dispute within 120 calendar days of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you

will be responsible for the amount listed on this GFE. If the reviewing agency disagrees with you and upholds the bill administered by your health care provider and/or facility, you will be responsible for the billed amount, even if it is higher than the estimated costs on the original GFE. To learn more and/or obtain a form to begin the appeal process, go to www.cnns.govinosurprises or call HHS.