Notice of the Right to Receive a Good Faith Estimate

Practice name: Kids Dentist Plus

Phone: (916) 226-6767
Email: [email protected]
Mailing address: 2190 E Bidwell St, Suite C, Folsom, CA 95630

In this Notice, “we,” “us,” “our,” and “our practice” refer to the dental practice entity or entities identified above.

Your Right to a Good Faith Estimate

Under federal law, if you are an uninsured or self-pay patient, you have the right to receive a Good Faith Estimate of the expected charges for dental items and services that you schedule with us or that you ask us to estimate. 

An estimate is not required upon scheduling when an item or service is scheduled fewer than three business days before it is to be furnished, such as emergency or walk-in care.

Who Is Eligible

You are an uninsured or self-pay patient for this purpose if you are not enrolled in Medi-Cal (including Medi-Cal Dental), Medicare, or another federal health care program, and either:

• you do not have dental or health coverage that provides benefits for the item or service; or
• you have dental or health coverage that provides benefits for the item or service, but you do not want a claim for it submitted to that coverage.

Eligibility depends on coverage for the particular dental item or service. Medical coverage that does not include dental benefits does not provide benefits for dental items or services, and a dental plan may not cover every dental item or service. Patients enrolled in Medi-Cal, Medicare, or another federal health care program generally are not eligible under this federal requirement, even if the program does not cover a particular item or service or the patient does not want a claim submitted.

A parent, legal guardian, or other authorized representative may request an estimate on a patient’s behalf. If you are unsure whether you qualify, ask our staff.

How to Request an Estimate

You may request a Good Faith Estimate in person, by telephone, or in writing, using the contact information above or by asking any staff member who schedules appointments or discusses costs. You do not need to complete a particular form, register for an online account, or use the words “Good Faith Estimate.” Any discussion or question about the expected cost of an item or service you are considering is treated as a request for an estimate. You may request an estimate before scheduling care. We will provide your estimate in writing, on paper or electronically, according to your requested delivery method.

When You Will Receive Your Estimate

• Care scheduled 3–9 business days in advance: We will provide your estimate no later than one business day after scheduling.
• Care scheduled 10 or more business days in advance: We will provide your estimate no later than three business days after scheduling.
• An estimate requested, including before scheduling: We will provide your estimate no later than three business days after your request.

Business days are Monday through Friday, excluding federal holidays.

What the Estimate Includes

A Good Faith Estimate lists the expected charges for the scheduled or requested dental items and services, and for items and services reasonably expected to be provided with them, based on the information available when the estimate is prepared.

The estimate is not a bill or a guarantee of final charges. Actual items, services, or charges may differ, including when additional care could not reasonably have been anticipated when the estimate was prepared. Any difference remains subject to applicable law and does not eliminate the dispute rights described in this Notice.

Our estimate includes the items and services we expect to furnish and bill. If a separately billing provider or facility, such as an independent anesthesia provider, hospital, or surgery center, is expected to be involved in your care, its charges may not appear on our estimate. You may request a Good Faith Estimate directly from that provider or facility.

If Your Bill Is Higher Than Your Estimate

If you receive a Good Faith Estimate and are later billed at least $400 more than the total expected charges listed on the estimate for the provider or facility that billed you, you may be eligible to dispute the bill through the federal patient-provider dispute resolution process. A dispute generally must be started within 120 calendar days after you receive the initial bill containing the disputed charges. Additional eligibility requirements and procedures apply.

Keep a copy or photograph of your Good Faith Estimate and your bill.

For More Information

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call the federal No Surprises Help Desk at 1-800-985-3059.