No Surprises Act Disclaimer

For individuals not using insurance, you have the right to receive a Good Faith Estimate that shows 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. If this happens, and your bill is $400 or more for any service from RSK Psychiatry, federal law allows you to dispute the bill.

The Good Faith Estimate is not a contract and does not require self-pay individuals to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate

You may contact RSK Psychiatry to let us know the billed charges are higher than the Good Faith Estimate. You can ask us to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. If you receive a bill that is at least $400 more than your good faith estimate, you can dispute the bill. If RSK Psychiatry provides you a Good Faith Estimate, please keep a copy or picture of it in a safe place.

There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate, reduced by the $25 fee. If the SDR entity 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 the process, go to www.cms.gov/nosurprises/consumers or call 1- 800-985-3059.