Good Faith Estimate (No Surprises Act) – Cash-Pay/Self-Pay Patients

If you choose to be seen as a cash-pay (self-pay) patient at Be Well Family Care, we will not bill your insurance for services provided during that visit.

What this means
By choosing cash-pay/self-pay, you understand that:

• You are financially responsible for all charges related to your visit
• Charges are based on the complexity of medical issues discussed and the length of the visit
• Payment is due at the time of service

Your Good Faith Estimate

A Good Faith Estimate is an expected range of charges for non-emergency care. The estimate below reflects services commonly provided during a visit at Be Well Family Care. Final charges may vary based on clinical judgment and medical necessity.

Office Visit Fee Ranges
(Pricing is based on visit complexity and time spent with the provider.)

• • **New Patient – Moderate Complexity:** $115–$193
  • **New Patient – Extended Visit:** $146–$244
  • **Acute (Sick) Visit:** $70–$100
  • **Established Patient – Moderate Complexity Visit:** $105–$150
  • **Established Patient – Comprehensive Visit:** $136–$195
  • **Annual Wellness Exam:** $125–$148

Functional Medicine Fee (when applicable)
A Functional Medicine Fee of $100–$150 is charged in addition to the Office Visit Fee for all visits except:

• • True Acute (Sick) Visits
  • Annual Wellness Exams

Additional services or testing

Additional charges may apply if your provider recommends additional services or testing during your visit, such as:

• • Urinalysis
  • Other in-office diagnostic testing
  • Other medically necessary services discussed during your appointment

If additional services are recommended that significantly change your estimate, we will discuss them with you whenever possible.

Vaccinations

• • Vaccination pricing is available upon request, as costs vary by vaccine.
  • For patients without insurance, vaccinations may be available at the county health department at low or no cost.

Important notes

• • This Good Faith Estimate is not a guarantee of final charges.
  • Final charges reflect the actual services provided and medical necessity.

Your rights under the No Surprises Act

You have the right to receive a Good Faith Estimate for the total expected cost of non-emergency healthcare services. If you receive a bill that is more than $400 higher than your Good Faith Estimate, you may have the right to dispute the bill. To learn more or to start a dispute, visit: www.cms.gov/nosurprises.

Payment and checkout policy

Payment is due at the time of your visit.
If you do not pay at checkout (or do not call Be Well Family Care to check out after a telemedicine visit), your credit card on file may be charged for any unpaid balances.