Good Faith Estimate & Surprise Billing Notice

This notice is posted on BCB’s website at the consent library URL referenced from the Jane practice-management system, is posted in BCB’s office, and will be provided to you in writing at the time of any scheduled self-pay or uninsured visit.

Your right to a Good Faith Estimate

If you are uninsured or are not using insurance for a service, you may have the right to receive a Good Faith Estimate explaining how much your care is expected to cost.

This may apply when you:

• do not have insurance,
• have insurance but choose not to use it for a service,
• are self-pay for the service, or
• ask for an estimate before scheduling or receiving care.

The Good Faith Estimate will include the expected charges for the primary service you are scheduling and any items or services that are reasonably expected to be provided by Bayou City Breastfeeding.

When you should receive a Good Faith Estimate

Appointments are booked before insurance information is collected, so we include our self-pay rates for expected charges in the booking confirmation sent to every patient when a visit is scheduled. If you are uninsured or choose not to use insurance, those rates are your estimate of expected charges for the visit you booked.

If your insurance plan is later determined not to cover your visit and you choose to proceed as a self-pay patient, we will provide a written estimate for that visit before any charge is made. You may request an individual written Good Faith Estimate at any time, and we will provide it within three business days.

If your bill is much higher than your estimate

If you receive a bill that is at least $400 more than your Good Faith Estimate, you may be able to dispute the bill through the federal patient-provider dispute resolution process.

You should save a copy or picture of your Good Faith Estimate. You may contact Bayou City Breastfeeding first to ask questions about the bill, request correction of an error, or discuss payment options.

Surprise medical billing protections

Federal surprise-billing protections under the No Surprises Act generally apply to certain emergency services, certain out-of-network services delivered at in-network hospitals or ambulatory surgical centers, and air-ambulance services. Texas surprise-billing protections under Texas Insurance Code Chapter 1467 (Senate Bill 1264) generally apply to facility-based and emergency providers in state-regulated health plans.

BCB is a private outpatient practice that does not provide emergency services and does not bill at hospitals or ambulatory surgical centers. The federal and Texas surprise-billing rules generally do not apply to BCB’s services. BCB will provide estimates and billing information as required by law and as described in the Payment-Related Consent.

Scope of the Good Faith Estimate

The Good Faith Estimate covers only BCB’s expected charges. If your care includes services billed by another provider (for example, a different practice, a referred specialist, or an outside laboratory), those charges are not included in BCB’s Good Faith Estimate. You may request a separate Good Faith Estimate from any other provider that schedules services for you.

Questions

For more information about federal medical-billing rights, visit the Centers for Medicare & Medicaid Services medical-bill rights resources at cms.gov/medical-bill-rights.

Electronic Signature, Governing Law, and Scope

Electronic Signature. If I sign this consent electronically, my electronic signature has the same legal effect as a handwritten signature under the federal E-Sign Act (15 U.S.C. §7001) and the Texas Uniform Electronic Transactions Act. The General Consent contains the full E-Sign consumer disclosure block applicable to all Bayou City Breastfeeding forms I sign.

Governing Law. This notice is governed by the laws of the State of Texas. Severability. If any provision of this consent is held invalid or unenforceable, the remaining provisions will remain in full force and effect.

Scope. This document addresses the matters set out above and does not limit or supersede any separate document I sign with Bayou City Breastfeeding, including the General Consent, the Treatment Consent for the service I am receiving, or any other practice form or policy.