Good Faith Estimate Notice
Good Faith Estimate Notice
Your Right to Receive a Good Faith Estimate
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House of Bloom Medical Aesthetics & Wellness is a direct-pay practice and does not bill insurance. Patients may request a Good Faith Estimate of anticipated charges before receiving services.
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Under federal law, health care providers are required to provide uninsured patients and self-pay patients with a Good Faith Estimate of expected charges for medical items and services before care is provided or upon request.
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A Good Faith Estimate outlines the costs of items and services that are reasonably expected for your health care needs based on information known at the time the estimate is created.
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Important Information
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The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. Actual charges may differ if complications, changes in treatment plans, additional services, laboratory testing, medications, or unforeseen circumstances occur.
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We encourage you to save a copy or take a picture of your Good Faith Estimate for your records.
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Direct-Pay Practice Disclosure
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House of Bloom Medical Aesthetics & Wellness operates as a direct-pay practice. Payment is due at the time services are rendered unless otherwise agreed upon in writing. We do not submit claims to insurance companies or participate in insurance billing.
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Patients are responsible for understanding any out-of-network benefits available through their insurance carrier. Upon request, we may provide documentation that patients can submit independently to their insurance company for possible reimbursement; however, reimbursement is not guaranteed and is determined solely by the patient's insurance plan.
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If Your Bill Is Higher Than Your Good Faith Estimate
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If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill.
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If your charges exceed your Good Faith Estimate, you may first contact House of Bloom Medical Aesthetics & Wellness to discuss the difference and attempt to resolve the matter directly.
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House of Bloom Medical Aesthetics & Wellness
509 Lafayette Blvd., Suite B
Fredericksburg, VA 22401
Phone: (540) 737-8464
Email: info@houseofbloommed.com
You may also initiate the Patient-Provider Dispute Resolution Process through the U.S. Department of Health and Human Services (HHS).
To use the dispute resolution process, you must begin the process within 120 calendar days of the date listed on the original bill.
A fee may apply to participate in the dispute resolution process. If the reviewing agency determines that the Good Faith Estimate should have been honored, you will generally only be responsible for the amount listed on the estimate. If the reviewing agency agrees with the provider or facility, you may be responsible for the higher billed amount.
Learn More
For additional information about your right to receive a Good Faith Estimate or the Patient-Provider Dispute Resolution Process, visit:
https://www.cms.gov/nosurprises
Or call: 1-800-985-3059
This notice is provided in accordance with the No Surprises Act and applicable federal regulations.
Direct-Pay Practice & No Surprises Act Information
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House of Bloom Medical Aesthetics & Wellness operates as a direct-pay healthcare practice and does not participate with insurance plans or submit claims to insurance companies.
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Because we do not provide emergency services and do not bill insurance, most federal balance billing protections related to out-of-network emergency care and hospital-based services do not apply to services provided at our practice.
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In accordance with the No Surprises Act, uninsured and self-pay patients have the right to receive a Good Faith Estimate of anticipated charges before receiving healthcare services. Patients may request a Good Faith Estimate at any time by contacting our office.
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If you have questions regarding pricing, treatment costs, membership programs, or anticipated charges, please contact our office before scheduling services.