Good Faith Estimate Notice (No Surprises Act)

Under federal law (the No Surprises Act), certain patients have the right to receive a Good Faith Estimate of expected charges for non-emergency healthcare services.

Who can get a Good Faith Estimate

You have the right to request or receive a Good Faith Estimate if you are:

• Uninsured (you do not have health insurance), or
• Self-pay (you have insurance but are choosing not to submit a claim for a service, or you are seeking services that are not covered).

If you plan to use insurance, your plan typically determines your cost-sharing (such as deductibles, copays, and coinsurance) and may provide additional cost information.

What a Good Faith Estimate is

A Good Faith Estimate is a written estimate of expected charges for healthcare items and services that are reasonably expected for your scheduled or requested service(s).

A Good Faith Estimate is not a contract and actual charges may differ based on your clinical needs and the services actually provided.

For information about our standard fees, please see our Fees page.

When you will receive a Good Faith Estimate

We will provide a Good Faith Estimate consistent with federal requirements, including:

• After you schedule a service at least 3 business days in advance, within the timeframes required by law (generally within 1 business day for services scheduled 3–9 business days ahead, and generally within 3 business days for services scheduled 10 or more business days ahead).
• Within 3 business days after you request a Good Faith Estimate for a service.

How to request a Good Faith Estimate

You can request a Good Faith Estimate by contacting us:

Robin Warner Neurology, PLLC
Phone: 201-719-5910
Email: [email protected]

To help us prepare it, please tell us:

• the service you are seeking (for example, initial visit or follow-up), and
• the date(s) you are considering (if known).

If you are billed more than your Good Faith Estimate

If you receive a bill that is at least $400 more than your Good Faith Estimate for the same items or services, you may have the right to use the federal patient-provider dispute resolution (PPDR) process.

Key points:

• You generally must start the dispute process within 120 calendar days of the date on the bill.
• The dispute process is administered by the U.S. Department of Health and Human Services (HHS).

For more information about the No Surprises Act and the PPDR process (including how to start a dispute), visit or call:

• cms.gov/nosurprises
• 1-800-985-3059

Updates to this notice

We may update this notice from time to time. The "Last Updated" date above indicates the most recent revision.