Your right to a Good Faith Estimate
If you are uninsured or paying for care yourself, you have the right to know what your care will cost before you receive it. This page explains that right and how to use it.
Ask us for an estimate any time
You have the right to receive a Good Faith Estimate of what your care will cost, in writing, before your visit. Call (408) 366-1735 or email info@peakptcupertino.com and ask. You do not need a reason, and asking costs nothing.
What a Good Faith Estimate is
The No Surprises Act was passed in 2020 to protect people from surprise medical bills. Those bills happen most often when a patient could not choose their provider, such as in an emergency.
The Good Faith Estimate is part of that law. It applies to every licensed health care provider, in any setting. It requires us to give you an estimate of what your care will cost if you are uninsured, self-pay, or paying in cash.
When you will get one from us
- When you schedule care with us and you are uninsured or paying yourself.
- Any time you ask, whether or not you have scheduled anything.
- Again, if your care changes and a new estimate is needed.
What the estimate covers, and what it does not
A Good Faith Estimate shows the cost of items and services that we reasonably expect you will need. It is not a contract, and it does not require you to receive the listed items and services.
- It does not include unknown or unexpected costs that may come up during treatment.
- We may recommend additional items and services as part of your course of care. Those must be scheduled separately and will not appear on this estimate. You will receive additional Good Faith Estimates for them when you schedule, or whenever you ask.
- The estimate is based on what is known at the time it is written. If complications or special circumstances come up, you could be charged more.
If your bill comes in much higher than the estimate
Federal law gives you the right to dispute it. If the amount you are billed is more than $400 higher than your Good Faith Estimate, you can start the patient-provider dispute resolution process.
How the dispute process works
- Submit a notification to the U.S. Department of Health and Human Services within 120 calendar days of getting the bill with the higher charges.
- There is a $25 fee to use the dispute process.
- If the reviewing agency agrees with you, you pay the price on the Good Faith Estimate. If it agrees with the provider, you pay the higher amount.
To learn more or get the form to start the process, visit cms.gov/nosurprises/consumers (opens in new tab) or call 1-800-985-3059. The full requirements for the dispute process are published at ecfr.gov, title 45, part 149 (opens in new tab).
Keep your estimate
Save a copy of any Good Faith Estimate we give you. You will need it if you ever want to dispute a bill. If you lose it, ask us and we will send you another.
Questions about cost
If anything about your benefits or what you will owe is unclear, ask our front desk. We would rather answer the question before your visit than have you find out on a bill. Call (408) 366-1735.
This notice is also available as a document you can save or print: Good Faith Estimate, about and disclaimers (PDF).
Ask what it costs before you come in
Call us and we will put your estimate in writing. Uninsured and self-pay patients have that right, and we are glad to use it.