Disclosure

Effective January 1, 2022, the No Surprises Act (Public Law 116-260) provides new federal protections against surprise medical billing. Under this law, you have the right to receive a Good Faith Estimate of expected charges before receiving healthcare services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy and related services.
• You can ask your healthcare provider for a Good Faith Estimate before you schedule a 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 for your records.

Under the No Surprises Act, healthcare providers are required to give patients who do not have insurance, or who choose not to use their insurance, an estimate of the expected charges for medical services. This is called a Good Faith Estimate.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. A Good Faith Estimate is not a contract or a guarantee of what you will be charged. Actual charges may differ if complications or unforeseen circumstances occur during treatment.

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

As a patient of HKD Outreach PC, you have the following rights:

• To be treated with respect, dignity, and consideration regardless of race, ethnicity, gender, sexual orientation, religion, disability, or socioeconomic status.
• To have your personal health information protected and kept confidential in accordance with HIPAA regulations.
• To participate in decisions about your treatment plan and to be informed of the risks and benefits of proposed treatments.
• To refuse or discontinue treatment at any time without penalty.
• To request access to your medical records and to request amendments to those records.
• To file a complaint or grievance without fear of retaliation.

HKD Outreach PC is committed to transparent billing practices. Please review the following policies:

• Co-pays are due at the time of service.
• Patients must provide 24-hour notice for appointment cancellations. Failure to provide adequate notice or a no-show will result in a $75 fee.
• We accept most major insurance plans. Please contact our office to verify your coverage.
• Self-pay rates are available upon request. A Good Faith Estimate will be provided prior to services.