Good Faith Estimate Disclaimer
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, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.
If you are billed for more than this Good Faith Estimate, you may 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.
If you dispute your bill, the provider or facility cannot move the bill for the disputed item or service into collection or threaten to do so, or if the bill has already moved into collection, the provider or facility has to cease collection efforts. The provider or facility must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility cannot take or threaten to take any retributive action against you for disputing your bill.
There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate, reduced by the $25 fee. If the SDR entity 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, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
This Good Faith Estimate is not a contract. It does not obligate you to accept the services listed above.
By typing my name below I acknowledge that I have received and reviewed this estimate.
Notice of Privacy Policies
I am required by the Health Insurance Portability & Accountability Act of 1996 (HIPAA) to provide confidentiality for all medical/mental health records and other individually identifiable health information in my possession. This Notice is to inform you of the uses and disclosures of confidential information that may be made by Tri-State Developmental Pediatrics (Michelle Zimmer, MD) and of your child's individual rights and Tri-State Developmental Pediatrics (Michelle Zimmer, MD) legal duties with respect to confidential information.
Ways in which I may use and disclose your protected health information:
I may use and disclose at my discretion your child's medical records for each of the following purposes only: treatment, payment and health care operations.
- Treatment means providing, coordinating or managing health care and related services.
- Payment means activities such as obtaining payment for the health care services our office provides for you from your insurance or another third-party payer.
- Health care operations include the business aspects of running a practice.
Our office may contact you on behalf of your child to provide appointment reminders or other services that may be of interest to you. I will disclose your protected health information to any person you identify that is involved in payment for your child's care.
Our office will use and disclose your child's protected health information when required by federal, state or local law. There are certain situations in which I am required by ethical standards to reveal information obtained during therapy to persons or agencies ¬ even if you do not give permission. These situations are as follows: (a) If your child threatens grave bodily harm or death to themselves or another person, I am required by ethical standards to inform the intended victim and/or appropriate law enforcement agencies; (b) if you or your child reports to me your knowledge of physical or sexual abuse of a minor child or any sexual conduct/contact with a minor, I am required by law to inform the appropriate child welfare or social agency which may then investigate the matter; (c) if I am required by a court of law (court order) to turn over records to the court or if I am ordered to testify regarding those records.
Any other uses and disclosures will be made only with your written authorization. You will be provided with an authorization form upon request. A separate form will be needed for each request for the release of information. The authorization for the release of records is valid until it expires or is revoked. You may revoke an authorization in writing and I am required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
By typing my name below, I indicate that I understand the use of my child's information for treatment, payment, and health care operations as stated above. I have been provided a copy of Tri-State Developmental Pediatrics privacy policies. I may ask at any time for a printed copy of these policies to keep in my files.