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ICÓNICA

good faith estimate

NOTICE: RIGHT TO A “GOOD FAITH ESTIMATE”

You have the right to receive a “Good Faith Estimate” explaining how much your medical and dental care will cost.

1. YOUR FEDERAL RIGHTS

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.

2. DENTAL SPECIFIC DISCLAIMERS (THE "CLINICAL REALITY")

  • Estimate, Not a Contract:The Good Faith Estimate is not a contract and does not require you to obtain the services from us. It is our best judgment of the cost based on the information known at the time of scheduling.
  • Unforeseen Complications:Dentistry is unpredictable. The Good Faith Estimate does not include costs for unknown or unexpected complications that may arise during treatment (e.g., a tooth requiring a root canal instead of a filling upon entering the tooth). If your clinical needs change during the procedure, you may be billed for these medically necessary services, and they may not be included in your original estimate.
  • Third-Party Fees:This estimate typically covers services provided directly by ICÓNICA DENTAL GROUP. It may not include costs for outside services, such as:
    • Pathology/Biopsy fees (if we send tissue to a lab).
    • Custom lab fees for specialized prosthetics.
    • Prescriptions filled at anoutside pharmacy.
  • Insurance Disclaimer:If you have dental insurance but choose not to use it (Self-Pay), you have the right to this e However, if you later decide to file a claim, this estimate may no longer apply, and insurance contracted rates will take precedence.

3. QUESTIONS & DISPUTES

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.