Good Faith Estimate Form

GOOD FAITH ESTIMATE FORM

The Surgical Center of the Treasure Coast

Estimated Statement

Patient Name:
Patient Address:
Patient Account Number:
Condition Requiring Services:
Date of Service:

CPT Code Procedure/Service Booked Gross Charge
Total Estimated Gross Charges Procedures/ Service Booked:

This is a good faith estimate of The Surgical Center of the Treasure Coast (SCTC) anticipated gross charges for its facility fees charged to pay SCTC for the procedure(s) that have been booked to be done at SCTC by your attending physician to treat your condition (the “Services”). It is being provided pursuant to Florida HB1175. Depending on whether the Services booked are, in fact, the services ultimately rendered to you while a patient of SCTC, the actual gross charges billed for SCTC facility fees may be higher or lower than this estimate.

In accordance with HB1175, SCTC is required to let you know that you may or may not pay less for the Services at another facility or in another health care setting. Please know that your attending doctor who booked your procedure(s) at SCTC may not be on the medical staff of such other facilities or health care setting. Furthermore, your attending physician who booked your procedures to be done at SCTC, and other health care providers, such as anesthesiologists, interoperative monitoring services, durable medical suppliers, and anatomical pathologists, some or all may provide services to you at SCTC, are not a part of SCTC facility fees and, if any other services are provided to you while being a patient of SCTC, the provider(s) will bill separately for their services rendered.

Gross charges are the “retail rates” billed by SCTC, before application of any adjustments for health insurance, health maintenance organization (“HMO”) or self-pay discounts. PLEASE BE ADVISED THAT THIS ESTIMATE HAS NOT AND WILL NOT BE ADJUSTED FOR ANY POTENTIAL SUCH DISCOUNTS. If SCTC believes that you have health insurance and/or HMO coverage(s) that may cover some or all of the services, SCTC may initiate contact with them to determine your cost-sharing responsibilities for SCTC’s bill. You may contact them directly as well for additional information concerning your cost-sharing responsibilities. If SCTC determines that you have cost-sharing responsibilities for SCTC, you will be required to pay your cost-sharing responsibilities in full on or before Services are provided. If you are unable to pay your cost-sharing responsibilities in full on or before Services are provided because you believe you are medically indigent, or you are not covered by an health insurance of HMO, upon request, SCTC, in its sole discretion, may offer you a discount on the amount due and/or offer a payment plan. Any such discount is considered by SCTC to be “charity care”. There is no formal application process for obtaining “charity care” at SCTC. SCTC’s standard collection policy is to produce and send one or more bills to patients for their coast sharing amounts, which if not paid on a timely basis, may then be placed with an attorney or collection to pursue such unpaid amounts. If accounts are placed with an attorney and/or collection agency, the costs charged by the attorney and/or collection agency will be passed onto the patient to pay, and the patients’ credit score may be negatively impacted.