Good Faith Estimate Policy

Effective Date: February 13, 2025

At Moonstone Mental Health Services PLLC, we are committed to transparency in healthcare costs. In compliance with the No Surprises Act, you have the right to receive a Good Faith Estimate (GFE) explaining how much your medical and mental health services will cost.

1. Your Right to a Good Faith Estimate

If you are uninsured or choose not to use your insurance, you are entitled to receive a Good Faith Estimate of expected charges for non-emergency services. This estimate provides an overview of the costs you may incur for services provided by Moonstone Mental Health Services PLLC.

2. When You Will Receive a Good Faith Estimate

- A Good Faith Estimate will be provided upon request before scheduling a service.

- If you schedule an appointment at least three business days in advance, you will receive the estimate no later than one business day after scheduling.

- If you schedule an appointment at least ten business days in advance, you will receive the estimate no later than three business days after scheduling.

3. What the Good Faith Estimate Includes

Your Good Faith Estimate will outline:

- The total expected cost of services

- A breakdown of individual service charges

- The timeframe during which the estimate is valid

- Any additional information regarding potential variations in costs

4. Understanding Your Estimate

The Good Faith Estimate is based on information available at the time and may be subject to change. It does not include unforeseen circumstances that may arise during treatment.

5. Dispute Resolution

If your final bill is at least $400 more than the Good Faith Estimate, you may dispute the charges. You can initiate a dispute by contacting the U.S. Department of Health & Human Services (HHS) within 120 days of receiving the bill.

For more information or to request a Good Faith Estimate, please contact us at:

Moonstone Mental Health Services PLLC

kadesha@moonstonemhs.com

319-853-8378

For more details about your rights, visit [www.cms.gov/nosurprises](https://www.cms.gov/nosurprises).