Good Faith Estimate

For any patients who call after January 1, 2022, Providers are required to provide uninsured and self-pay patients with Good Faith Estimates of expected charges for all scheduled services and items prior to care and upon request when shopping for care. The Good Faith Estimates show the costs of items and services that are reasonably expected for your health care needs for an item or service. 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. You could be charged more if complications or special circumstances occur.

Make sure to save a copy or picture of your Good Faith Estimate.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

If the charges are higher than the Good Faith Estimate, you may contact Williams Family and Cosmetic Dentistry at 813-560-0447 and resolve the issue or you may start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) 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 have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1- 800-985-3059.

Good Faith Estimate

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For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1- 800-985-3059.

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