NOTICE OF YOUR RIGHT TO RECEIVE A GOOD FAITH ESTIMATE

For Uninsured or Self-Pay Clients

You have the right to receive a Good Faith Estimate explaining how much your health care will cost.

Under federal law, health care providers must give individuals who do not have certain types of health coverage, or who have coverage but are choosing not to have a claim submitted for these services, an estimate of expected charges for non-emergency health care items and services before those items or services are provided.

• You have the right to receive a Good Faith Estimate for the total expected cost of non-emergency health care items or services, including psychotherapy, when you request an estimate or when you schedule care far enough in advance.

• If you schedule an item or service at least 3 business days in advance, the Good Faith Estimate must generally be provided in writing within 1 business day after scheduling. If you schedule at least 10 business days in advance, it must generally be provided within 3 business days after scheduling. You may also request an estimate before scheduling; when you do, it must generally be provided within 3 business days after your request.

• If you receive a bill from a provider or facility that is at least $400 more than the Good Faith Estimate from that same provider or facility, you may have the right to dispute the bill through the federal Patient-Provider Dispute Resolution process.

• Keep a copy of your Good Faith Estimate so you can compare it with any bills you receive.

To request a Good Faith Estimate from Yvette Lawhorn, PLLC, call 617-468-8570 or email yvette@yvettelawhorn.com.

For more information about your federal rights, visit www.cms.gov/medical-bill-rights or call the No Surprises Help Desk at 1-800-985-3059.

If you need this information or a Good Faith Estimate in another accessible format or need assistance accessing it in another language, please contact the practice.

This notice explains your federal right to receive a Good Faith Estimate. It is not itself an estimate of your charges.