In accordance with the No Surprise Bill Act, Retina Associates of Western NY, P.C. will provide a good faith estimate for services scheduled for a patient upon request. The good faith estimate will include items that are reasonably expected to be provided in conjunction with the scheduled service. You’ll be provided with an estimate of the anticipated charges that Retina Associates of Western NY, P.C. would bill to insurance for services rendered and your out-of-pocket costs. The estimate is based on the information provided at the time of request and is not a guarantee of final out-of-pocket costs. We cannot guarantee coverage or payment by applicable insurance providers and encourage you to contact your provider directly for more information about your coverage and benefits.The good faith estimate can be provided in the patient’s language upon request.
To request a good faith estimate please contact the Cost Estimate Team at email@example.com or via phone: 585-442-3411 ext 126.
This Good Faith Estimate 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, federal law allows you to dispute (appeal) the bill.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are 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/consumers or call 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/consumers or call 1-800-985-3059.