Chester River Behavioral
Health and Wellness
OMB Control Number 0938-1401
Expiration Date 12/31/2022
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
A Good Faith Estimate shows the costs of services that are reasonably expected for the services necessary to address your mental health care needs. The estimate is based on the information known to [us/me] when [we/I] complete the estimate.
The Good Faith Estimate does not reflect any payments from your insurer(s) nor does it 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, a revised GFE will be provided to you.
If you are billed $400 more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact your provider at Chester River Behavioral Health to let them know the billed charges are more than $400 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 if there 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, 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 or call CMS at 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059 .
This Good Faith Estimate is not a contract. It does not obligate you to accept the services listed above.