No Surprises Act and Good Faith Estimate

for Uninsured and Self-Pay Patients

Under the No Surprises Act, you have a right to a Good Faith Estimate.

You have the right to a written estimate of your medical bill (called a Good Faith Estimate) when:

• Your appointment is scheduled 3 or more days in advance and

• You will not be using insurance to pay for the visit or, you do not have insurance.

You may also request an estimate if one is not automatically provided.

The Good Faith Estimate will include the expected charges of the item or service, such as: the cost of the non-emergent clinic visit, plus any tests, procedures, and supplies. As a service to you, we provide a fee schedule for all of our patients to view so they know the Good Faith Estimate for all services. 

Make sure to save a copy or photo of your Good Faith Estimate. If you receive a bill from us that is at least $400 more than your estimate, you can dispute it. This must be done within 120 calendar days of receiving the bill.

If you have questions

Our patient account representatives can answer questions about your Good Faith Estimate and explain the possible costs of your care.

Mental Wellbeing NP Phone - (612) 662-9604

For more information about your rights and the No Surprise Bill Act, visit: www.cms.gov/nosurprises.