No Surprises Act, Good Faith Estimate:

This applies to uninsured, self-pay, or excluded/non-covered services. Please see the Disclaimer below. Dr. Shapiro understands good health care can be expensive. As a result, there are additional, usually more affordable, options for these type services through Medical Discount Plans or Discount Managed Care Organizations. You may ask Dr. Shapiro about these options. Please click the link for the disclaimer

Disclaimer:

This Good Faith Estimate only provides an estimate of the charges for those items or services reasonably expected to be furnished to you upon your receipt of the scheduled/requested primary item or service. There may be additional items or services which the provider recommends as part of your course of care that you will be required to schedule separately which may not be reflected in this Good Faith Estimate. An additional estimate may be required.

This estimate is only valid for 4 months from the date of the estimate. If the actual charge for these services exceeds our estimate by the greater of: (i) $100; or (ii) 5%, we will provide a written explanation as to why the charges exceed the estimate. This Good

Faith Estimate is not a contract and does not require you to obtain any of the items or services from any of the providers or facilities identified in this Good Faith Estimate. If you are uninsured or do not intend to submit your charges to your health plan (“self-paying”) and you are billed at least $400 more than this Good Faith Estimate, you have the right to dispute the bill. If you are uninsured or self-paying, you may contact the health care provider or facility to let them know the billed charges are higher than the Good Faith Estimate and ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

Uninsured or self-paying individuals may also start a dispute resolution process for uninsured with the U.S. Department of Health and Human Services (HHS). If you choose to do so, 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 (updated annually) to use the dispute resolution process for uninsured and self-paying individuals. 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. To learn more and get a form to start this process, go to www.cms.gov/nosurprises or call 1-800-985-3059.