Family Guidance Centers
Your Right to Receive a Good Faith Estimate
If you do not have health insurance or do not plan to use certain health insurance coverage to pay for your care, you have the right to receive an estimate of your expected charges before services are provided.
You have the right to know what your care may cost
Under federal law, health care providers must give patients who do not have certain types of health care coverage, or who are not using certain types of health care coverage, a Good Faith Estimate explaining the expected charges for scheduled or requested health care items and services.
A Good Faith Estimate is not a bill. It is a written estimate based on the information known when the estimate is prepared.
Who may receive a Good Faith Estimate?
This right generally applies when you:
- do not have health insurance or other qualifying health care coverage; or
- have certain health insurance coverage but do not plan to submit a claim to that coverage for the scheduled or requested service.
If you are enrolled in Medicare, Medicaid, another federal health care program, or a health plan with requirements affecting self-payment, different rules may apply. Please contact Family Guidance Centers before choosing not to use that coverage.
How to request an estimate
You may request a Good Faith Estimate before scheduling services or when you schedule an appointment. A discussion or question about the potential cost of services will be treated as a request for a Good Faith Estimate when the federal rules require it.
Phone: 804-743-0960
Mailing address: 6603 Irongate Square, North Chesterfield, VA 23234
You may also ask any Family Guidance Centers administrative staff member for assistance. Please tell us that you are requesting a Good Faith Estimate and whether you prefer to receive it on paper or electronically.
When you should receive your estimate
Services scheduled 3–9 business days ahead
We will provide the written estimate no later than 1 business day after scheduling.
Services scheduled 10 or more business days ahead
We will provide the written estimate no later than 3 business days after scheduling.
Estimate requested before scheduling
We will provide the written estimate no later than 3 business days after your request.
If a service is scheduled fewer than 3 business days in advance, federal law may not require a Good Faith Estimate before that appointment. You may still ask us about expected charges.
What your individualized estimate will include
Your written Good Faith Estimate will include information required by federal law, such as:
- your name and date of birth;
- a description of the primary service or expected course of care;
- the services reasonably expected to be provided during the estimated period of care;
- applicable diagnosis and service codes when required;
- the expected charge for each listed service;
- the provider’s identifying information and service location; and
- required explanations about separate services, possible changes, and your dispute rights.
For recurring outpatient therapy, one estimate may cover an anticipated frequency and number of sessions for a period of up to 12 months. A new estimate may be provided if the anticipated services, frequency, duration, provider, location, or charges change, or if care is expected to continue beyond the period covered by the estimate.
Important information about the estimate
- The estimate will reflect the services reasonably expected based on the information available when it is prepared.
- Actual services or charges may differ if your treatment needs or other circumstances change.
- Additional services that must be scheduled separately may not be included. You may request a separate estimate for those services.
- A Good Faith Estimate is not a contract and does not require you to receive services from Family Guidance Centers or any provider identified in the estimate.
- Keep a copy of your estimate so that you can compare it with future bills.
If your bill is at least $400 more than your estimate
If the billed charge from a provider or facility is at least $400 more than the expected charge shown for that provider or facility on your Good Faith Estimate, you may be eligible to use the federal patient-provider dispute resolution process.
You generally must start the dispute within 120 calendar days of the date on the initial bill. Starting a dispute will not adversely affect the quality of the health care services you receive from Family Guidance Centers.
Learn more or start a dispute:
- CMS information about disputing a medical bill
- Federal Patient-Provider Dispute Resolution Portal
- Call the federal No Surprises Help Desk at 1-800-985-3059
The federal dispute process may require an administrative fee. Check the CMS website or contact the No Surprises Help Desk for the current amount and instructions.
If you plan to use insurance
This notice concerns the federal Good Faith Estimate right for uninsured or self-pay individuals. If Family Guidance Centers will submit claims to your health plan, your actual responsibility may depend on eligibility, benefits, deductibles, copayments, coinsurance, medical-necessity rules, authorization requirements, and how your plan processes the claim. Information supplied by Family Guidance Centers about benefits is not a guarantee of payment. Contact your health plan for plan-specific cost information.
Language assistance and accessible formats
Free language assistance and appropriate auxiliary aids and services are available. Family Guidance Centers can arrange qualified spoken-language interpreters by audio or video, qualified American Sign Language (ASL) interpreters by video, and information in appropriate alternate formats. Call 804-743-0960 or speak with your provider or an administrative staff member.
For additional information, visit our Notice of Nondiscrimination and Language Assistance .