Good Faith Estimate Notice
Your Right to a Good Faith Estimate
At Good Samaritan Health & Wellness Center, we are committed to providing transparent information about the cost of your healthcare services.
Under the No Surprises Act, patients who are uninsured or choose to pay for their healthcare services themselves (self-pay patients) have the right to receive a Good Faith Estimate of expected medical charges before receiving care.
What Is a Good Faith Estimate?
A Good Faith Estimate provides an estimate of the expected charges for medical items and services, including reasonably anticipated related services, that may be provided during your visit. The estimate helps you understand and plan for your healthcare costs before receiving treatment.
Who Can Receive a Good Faith Estimate?
You are entitled to receive a Good Faith Estimate if you:
- Do not have health insurance coverage.
- Choose not to use your health insurance for a particular service.
- Request an estimate of charges before scheduling or receiving services.
How Do I Request a Good Faith Estimate?
You may request a Good Faith Estimate by contacting our office before scheduling a service or at any time prior to receiving care.
Good Samaritan Health & Wellness Center
Phone: 706-253-4633
Email: reception@goodsamhwc.org
Address: 175 Samaritan Dr. Jasper, GA 30143
Our staff will be happy to assist you with obtaining an estimate of expected charges.
Important Information
- A Good Faith Estimate is an estimate only and is not a bill.
- Your actual charges may differ if unexpected or additional services are medically necessary.
- You may receive separate estimates from other providers involved in your care.
- Keep a copy of your Good Faith Estimate for your records.
If Your Bill Is Higher Than Your Estimate
If you receive a bill that is at least $400 more than your Good Faith Estimate, you may be eligible to initiate the federal Patient-Provider Dispute Resolution (PPDR) Process.
For more information about your rights under the No Surprises Act, visit the Centers for Medicare & Medicaid Services Medical Bill Rights website: