Your Right to a Good Faith Estimate

Your right to a Good Faith Estimate

Under the federal No Surprises Act (Public Health Service Act § 2799B-6, 45 CFR 149.610), health care providers must give patients who do not have insurance, or who are not using insurance to pay, an estimate of the expected charges for medical items and services.

You have the right to receive a Good Faith Estimate (GFE) for the total expected cost of any non-emergency items or services, including related costs like medical tests, prescription drugs, equipment, and facility fees.

When you will receive a Good Faith Estimate

Axis Pain & Anesthesia Group will provide you with a written Good Faith Estimate if you are:

• Uninsured — you do not have health insurance, or
• Self-pay — you have health insurance but choose not to use it to pay for the item or service (including when you are asking to be billed only on a lien arrangement)

The estimate will be provided:

• Within 1 business day if you schedule an item or service at least 3 business days in advance
• Within 3 business days if you schedule at least 10 business days in advance
• Within 3 business days of your request if you ask for an estimate without scheduling (for example, if you are comparing prices)

What the Good Faith Estimate includes

A Good Faith Estimate from Axis Pain & Anesthesia Group will include, in writing:

• Your name and date of birth
• A description of the primary item or service (for example, “lumbar epidural steroid injection under fluoroscopy”)
• An itemized list of expected items and services reasonably likely to be provided in a single scheduling period, including facility fees, anesthesia charges, imaging-guidance fees, and physician professional fees, each with its own diagnostic (ICD-10) and service (CPT/HCPCS) code where available
• The expected charge for each item and service
• The name, NPI, and Tax ID of the provider (Axis Pain & Anesthesia Group) or, where applicable, co-providers and co-facilities
• A disclaimer that the GFE is an estimate, not a contract, and that actual items, services, or charges may differ
• A disclaimer explaining your right to dispute a bill that exceeds the estimate by more than $400

If your bill is more than $400 higher than your estimate

If you receive a bill that is at least $400 more than the total expected charges in your Good Faith Estimate, you can dispute the bill through the federal patient-provider dispute-resolution process.

To start the dispute:

• You must begin the dispute process within 120 calendar days from the date on the original bill
• There is a $25 fee to use the dispute process (the fee may be refunded if you win the dispute)
• If the dispute decision goes in your favor, you will only be required to pay the amount in your Good Faith Estimate (possibly plus a small administrative amount)
• If the agency-selected dispute-resolution entity agrees with the provider, you will pay the billed amount

Start a dispute or learn more:

• Online: www.cms.gov/nosurprises
• By phone: 1-800-985-3059

How to request a Good Faith Estimate

If you are uninsured or plan to self-pay, you can request a written Good Faith Estimate at the time of scheduling, or in advance:

• By phone: (562) 252-0816
• By email: [email protected] — put “Good Faith Estimate request” in the subject
• In person at any of our offices (Downey, Tarzana, or Bakersfield)

When you request an estimate, please tell us:

• What items or services you are asking about (for example, “cervical medial branch block”)
• Whether you would like this done at our Downey, Tarzana, or Bakersfield office
• Whether you are uninsured or choosing to self-pay
• A preferred delivery method (email, mail, or in person)

We will deliver the written estimate within the timeframes described above. If the estimate does not reach you in that time, please call us and we will follow up.

Important limits of a Good Faith Estimate

• A Good Faith Estimate is not a contract. It does not obligate you to accept the items or services listed.
• The estimate reflects expected charges. Actual charges may differ if your clinical needs change during care, if additional items or services become necessary, or if a different provider participates in your care.
• A Good Faith Estimate is not a substitute for insurance. If you have insurance and would like us to bill your plan, this process does not apply — you should receive an Explanation of Benefits from your insurer after your care instead.
• A Good Faith Estimate does not include charges from independent providers outside our practice (for example, an outside laboratory or hospital) unless that provider has been identified as a co-provider in the estimate.

If you have a question or need help

Our billing team is happy to walk you through an estimate. Please call (562) 252-0816 or email [email protected].

This notice was last updated on April 22, 2026. For more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.