⚠️ Template content. This document is a substantively complete template prepared for review. It must be reviewed and finalized by Pasadena Clinical Group's California-licensed healthcare attorney and compliance officer before publication.

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You have the right to receive a "Good Faith Estimate" 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.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

2. When you'll receive your Good Faith Estimate

If you are uninsured or self-paying for your care at Pasadena Clinical Group, we will provide you with a written Good Faith Estimate after we know what services you'll need and before scheduling. The estimate will list expected items and services, the fee for each, and the diagnostic/procedural codes that apply.

3. Dispute resolution process

If you receive a bill that is at least $400 more than the Good Faith Estimate for that item or service, you may initiate a patient-provider dispute resolution process under 45 CFR §149.620. You must initiate the process within 120 calendar days of receiving the bill. Disputes are handled by certified independent dispute resolution entities; visit cms.gov/nosurprises for instructions.

4. Billing contact

For Good Faith Estimate requests or billing questions, contact our billing line at (626) 354-6440 or email office@pasadenaclinicalgroup.com.

Questions or requests

For questions about this document or to exercise any of the rights described, contact us: