Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost. This estimate is part of the No Surprises Act, effective 1/1/2022. Health care providers are required to give patients who do not have health insurance or who have health insurance and decide not to use it, a Good Faith Estimate. A Good Faith Estimate includes an estimate of services to be provided, including their frequency, duration, and cost. Questions related to the Good Faith Estimate may be directed to FBTA at 763-780-1520.

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• We will provide you with a Good Faith Estimate upon request or when scheduling an appointment for services.

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• If you schedule an appointment at least three days in advance, you will be provided a Good Faith Estimate in writing within one business day upon making the appointment. For persons who schedule an appointment at least ten days in advance, we will provide you with a written Good Faith Estimate within three business days of schedule the appointment.

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• Should you receive a bill that is $400 or more over your Good Faith Estimate, there is a patient-provider dispute resolution process which can be implemented through the Department of Health and Human Services to dispute your bill.

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• We encourage you to save a digital and/or hard copy of your Good Faith Estimate.

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• It may be that the clinical picture relative to your care may change the nature and/or scope of the services being provided to you. If this occurs, we are required to clearly convey this to you and to provide an amended Good Faith Estimate to reflect such changes