No Surprises Act & Good Faith Estimate

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency item or service. This includes related costs like medical tests, prescription drugs, and equipment, where reasonably foreseeable at the time the estimate is prepared.
• You can ask any health care provider or facility for a Good Faith Estimate before you schedule.
• If you schedule at least 3 business days in advance, you must receive a Good Faith Estimate in writing within 1 business day. If at least 10 business days in advance, within 3 business days.
• Make sure to save a copy or picture of your Good Faith Estimate.

The standard charge for a video consultation with BraveWorms Medical, P.C. is published at /pricing. When you book, the intake confirmation email serves as your Good Faith Estimate and itemizes:

• The visit fee.
• Any medications likely to be prescribed and a typical retail-price range (you pay the pharmacy directly).
• Any tests likely to be ordered and a typical price range from common reference labs (you pay the lab directly).

Tests and prescriptions ordered to outside facilities are billed by those facilities, not by us. We have no control over the prices those facilities charge and we receive no payment from them.

If you receive a bill from us that is at least $400 more than the Good Faith Estimate, you can dispute the bill. You may:

• Contact us first at billing@braveworms.com to ask for an updated bill, negotiate, or ask if financial assistance is available.
• Initiate the federal patient-provider dispute resolution process within 120 calendar days of the bill date by visiting cms.gov/nosurprises or by calling 1-800-985-3059.

There is a $25 fee to use the dispute process. If the federal Selected Dispute Resolution entity agrees with you, you will pay the price on the Good Faith Estimate. If it agrees with us, you will pay the higher amount.

If you have insurance

The No Surprises Act protects insured patients from "surprise" out-of-network bills for emergency services and certain non-emergency services at in-network facilities. Because BraveWorms Medical, P.C. does not participate with insurance plans, this billing scenario does not arise from our visits, you pay our published self-pay rate directly and may submit a superbill to your insurer at your option.

If you are uninsured or self-pay

The Good Faith Estimate process described above applies.

For questions about your rights under the No Surprises Act, visit cms.gov/nosurprises or call 1-800-985-3059.