Cash Rates

Good Faith Estimate Disclaimer You have the right to receive a “Good Faith Estimate” (GFE) explaining how much your medical care will cost. 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 when an appointment has been scheduled 3 or more days in advance. 

• Texoma Retina and Glaucoma may, as part of the course of care, recommend additional services that will need to be scheduled or requested separately and are not reflected in the GFE; 

• The GFE is only an estimate of items or services reasonably expected to be furnished at the time it was issued, and that actual items, services, or charges may differ from the GFE; 

• The GFE is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from Texoma Retina and Glaucoma or any other provider listed. 

• The patient may initiate the patient-provider dispute resolution process if the actual billed charges are “substantially in excess of” (currently defined as more
than $400 greater than) the expected charges included in the Good Faith Estimate, as specified in 45 CFR 149.620: o You may contact our office to let us know the billed charges are higher than the Good Faith Estimate. 

o You can ask us to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. 
o You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
o There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
o Initiating the patient-provider dispute will not adversely affect the quality of healthcare services furnished to the patient.
o To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059.