No Surprises Notice

Standard Good Faith Estimate for Patients

Dental offices should provide uninsured/self-pay patients with an estimate of their bill for dental items and services before those items or services are provided. This estimate is not a contract and does not require that you obtain these services at this office. This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service; it may not include additional items that may be recommended for post treatment care or rehab services. Please note that the estimate is based on information known at the time the estimate was created.

• You have the right to receive a Good Faith Estimate for the total expected cost of any dental services upon request or when scheduling services.
  • Please note: 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.
  • If we refer you to a specialist, you must ask them for an estimate for the services they provide; we have no access to their treatment recommendations, fee schedules, etc.
• You can also ask your dental care office for a Good Faith Estimate before you schedule a service. If you do, make sure the dental office gives you a Good Faith Estimate in writing within 3 business days after you ask. Information regarding scheduled items and services must be furnished within 1 business day of scheduling an item or service to be provided in at least 3 business days; and is not required if requested fewer than three days in advance or for emergency services.
• If you receive a bill that is at least $400 more for a single procedure than your Good Faith Estimate amounts, not including any fees from complications/emergencies, you can dispute the bill.
  • (Example: if the dental office says a 2 surface filling on tooth #29 is $150, and then they charge $550, you can dispute the bill. If the tooth #29 ends up needing a crown for $1000 because there was so much decay they couldn’t do a 2 surface filling, that is a complication and you can’t dispute the crown, even though the amount is more than $400)
  • You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask ifthere is financial assistance available.
  • You may also 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, youwill have to pay the higher amount.
• Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For questions or more information about your right to a Good Faith Estimate, visit https://www.cms.gov/medical-bill-rights, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.