Version: good-faith-estimate-2026-09-05-r1

Your Right to a Good Faith Estimate

Effective date: 2026-09-05

If you do not have health insurance or you are not using insurance for these services, federal law entitles you to receive a written Good Faith Estimate of expected charges for scheduled services and items reasonably expected with them.

Ingleside's physician records-review and opinion services are self-pay and are not submitted to insurance. A Good Faith Estimate is not a promise that an insurer, health plan, FSA, HSA, or other payer will cover or reimburse the service. A receipt or superbill, if offered, does not guarantee reimbursement.

• You may ask Ingleside Health for a Good Faith Estimate before scheduling a service.
• If you schedule a service at least three business days in advance, we will provide the estimate within the timeframe required by law.
• The estimate will describe the expected service, anticipated charges, and applicable diagnostic/service codes when required.
• The estimate is not a contract and may change if you request or require additional services. We will explain material scope changes and provide an updated estimate when appropriate.
• If a bill from a provider or facility is at least $400 more than that provider's or facility's Good Faith Estimate, you may be able to use the federal patient-provider dispute process.

Keep a copy of your Good Faith Estimate. To request one, use the billing contact below. Learn more at cms.gov/nosurprises/consumers.

Betula Mental Health PLLC
Ingleside Health service
daniel@inglesidehealth.com