Good Faith Estimate

Receive a Good Faith Estimate

For people who are uninsured or choose to pay for care themselves. This does not apply to persons utilizing insurances including Medicaid, Medicare and Commercial Insurers.

You have the right to receive a written Good Faith Estimate explaining how much the care FSA expects to provide may cost. The estimate is not a bill and does not require you to receive the services.

• When you will receive it: If you schedule a service 3 to 9 business days in advance, FSA must provide the estimate within 1 business day after scheduling. If you schedule 10 or more business days in advance, it must be provided within 3 business days. If you request an estimate before scheduling, it must be provided within 3 business days after your request.
• What it includes: The estimate lists services FSA reasonably expects to provide and the expected charges, based on information available when it is prepared. It may reflect your sliding fee discount when applicable. You may request it on paper or electronically.
• How to compare your bill: If FSA’s bill is at least $400 more than the estimate for the listed services, you may have the right to dispute the charge through the federal Patient-Provider Dispute Resolution process.

To request an estimate or ask about costs, contact FSA:

Phone:847-695-3680 x114
Email: fsaintake@fsaelgin.org

Learn more about estimates and disputes at cms.gov/nosurprises or call 1-800-985-3059.

Keep a copy of the estimate to compare with your bill. The estimate is based on information available when it is prepared; additional services or charges may arise that could not be anticipated.