Good Faith Estimate

Under the No Surprises Act, uninsured patients and patients who choose not to use insurance may have the right to receive a Good Faith Estimate of expected charges before receiving scheduled health care services. CMS states that uninsured or self-pay consumers generally must be given a good faith estimate of what they may be charged before they receive an item or service. A Good Faith Estimate is not a bill. It is an estimate of expected charges based on the information available at the time it is prepared.

Who May Request a Good Faith Estimate?

  • You may request a Good Faith Estimate if:

  • You do not have health insurance

  • You choose not to use insurance for your care

  • You are self-pay

  • You want an estimate before scheduling or receiving services

CMS explains that the No Surprises Act gives uninsured or self-pay individuals the ability to receive an estimate of expected charges before care.

What May Be Included?

A Good Faith Estimate may include expected charges for scheduled services such as:

  • Psychiatric evaluation

  • Medication management

  • Therapy

  • Follow-up visits

  • Other services expected at the time of scheduling

The estimate may not include unexpected or unknown services that arise later. Your actual charges may differ if your care changes, additional services are needed, or clinical needs change.

Insurance and Estimates

If you are using insurance, your actual patient responsibility depends on your insurance plan, deductible, copay, coinsurance, network status, coverage rules, authorization requirements, and claim processing. Santana Mental Health Services may verify insurance eligibility or benefits as a courtesy, but verification is not a guarantee of payment, coverage, network status, authorization, medical necessity, or final patient responsibility.

Questions About Your Estimate

For questions about a Good Faith Estimate, self-pay rates, insurance coverage, or expected patient responsibility, please contact Santana Mental Health Services.

Santana Mental Health Services LLC
5901 SW 74th St, Suite 211
South Miami, FL 33143
Phone: 786.228.6892
Fax: 786.414.3622
Email: admin@santanamhs.com

This page is provided for general patient information and does not replace Santana Mental Health Services’ full intake forms, consent forms, privacy notices, financial agreements, or applicable law. If there is any conflict between this page and the signed patient forms, the signed forms and applicable law control. Patients may contact Santana Mental Health Services with questions.