Good Faith Estimate & No Surprises Act

• Automatically, in writing, whenever you schedule as a self-pay or uninsured patient — at least 1 business day before a visit scheduled 3–9 business days out, and at least 3 business days before a visit scheduled 10 or more days out.
• Any time you ask for one, before scheduling, within 3 business days of your request.
• In a format you can keep — paper or electronic — including expected charges for the evaluation, follow-up visits, and any related services we reasonably expect to provide.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you may dispute the bill through the federal patient–provider dispute resolution process. Start the dispute within 120 calendar days of the date on the bill. Keep a copy of your estimate. For questions or to start a dispute, visit cms.gov/nosurprises or call 1-800-985-3059.

When you receive emergency care or are treated by an out-of-network provider at an in-network facility, you are protected from surprise billing and balance billing. You are responsible only for your in-network cost-sharing amount. These federal protections are reinforced in Illinois by the Network Adequacy and Transparency Act (215 ILCS 124) and the Illinois surprise-billing provisions of the Insurance Code. We will never ask you to waive these protections as a condition of receiving care.

• If you use insurance, your final cost depends on your plan's deductible, coinsurance, copay, and whether prior authorization is required. We verify benefits before your first visit and tell you what we find.
• An estimate is not a contract and does not obligate you to receive care. Costs can change if your clinical needs change — for example, if a visit is extended for combined medication management and psychotherapy.
• Ask us about self-pay rates and payment plans. We will tell you our fees in plain language before you commit to anything.

Call (708) 948-7039 or email docs@sanevihs.com and ask for a Good Faith Estimate. Please do not include clinical details in email.