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813-973-4747
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813-973-4747

Good Faith Estimate

[Name of Clinic/Practice/Business]
[Provider Name]
NPI: [Provider NPI], TIN: [Provider/Clinic Tax Identification Number]
[Street Address, City, State, Zip – Where service will be provided]
[Phone Number]

Good Faith Estimate 

Patient Name:

Date

of Birth:

 

 

Estimated Services and Items

 

 

Date of Appointment

 

 
Description (clear language)Diagnosis Code (ICD-10 Code)

Service Code

(CPT, HCPCS, DRG)

Quantity

Expected

Cost

Primary service description here (P)    
     
     
     
     
     
     

P – Primary Service (initial reason for visit) C – Co-provider services

R – Reoccurring Services or item (valid for up to 12 months from date on this form)

Total Expected Charges          $ 
Date of Good Faith Estimate: 

Disclaimers:

The Diagnosis listed above is only a working diagnosis that may change pending the outcome of the physician’s full examination.

There may be additional items or services that we recommend as part of the course of care that must be scheduled or requested separately and are not reflected in this good faith estimate.

The information provided in this good faith estimate is only an estimate of items or services reasonably expected to be furnished at the time this good faith estimate was and actual items, services, or charges may differ from the good faith estimate.

You have the right to initiate the patient-provider dispute resolution process if the actual billed charges are $400 more than the expected charges included in the good faith estimate and the dispute is initiated within 120 days after the date of the bill for the items or services. To start the process, you may contact us at the phone number or address listed above 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. You may also start a dispute resolution process with the U.S. Department of Health and Human Services within 120 calendar days (about 4 months) of the date on the original bill and if the agency disagrees with you, 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.

This good faith estimate is not a contract and does not require you to obtain the items or services from any of the providers or facilities identified in the good faith estimate.

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    Contact

    813-973-4747
    27454 Cashford Circle
    Wesley Chapel, FL 33544

    Business Hours

    Table Header Table Header
    Monday
    8:00AM - 5:00PM
    Tuesday
    8:00AM - 6:00PM
    Wednesday
    8:00AM - 5:00PM
    Thursday
    8:00AM - 6:00PM
    Friday
    7:00AM - 3:00PM
    Sat - Sun

    Closed

    Contact

    813-973-4747
    27454 Cashford Circle
    Wesley Chapel, FL 33544

    Business Hours

    Monday
    1:00PM – 5:00PM

    Tuesday
    Closed

    Wednesday
    1:00PM – 5:00PM

    Thursday
    Closed

    Friday
    1:00PM – 3:00PM

    Sat – Sun
    Closed

    Contact

    813-973-4747
    326 W. Bearss Ave.
    Tampa, FL 33613

    Business Hours

    Table Header Table Header
    Monday
    1:00PM - 5:00PM
    Tuesday
    Closed
    Wednesday
    1:00PM - 5:00PM
    Thursday
    Closed
    Friday
    1:00PM - 3:00PM
    Sat - Sun

    Closed

    Contact

    813-973-4747
    326 W. Bearss Ave.
    Tampa, FL 33613

    Business Hours

    Monday
    8:00AM – 2:00PM

    Tuesday
    1:00PM – 5:00PM

    Wednesday
    8:00AM – 2:00PM

    Thursday
    1:00PM – 5:00PM

    Friday
    9:00AM – 2:00PM

    Sat – Sun
    Closed

    Schedule Appointment

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