GOOD FAITH ESTIMATE

Good Faith Estimate Policy

CogniVita Center for Neuropsychology
Effective Date: December 1, 2025

Under the No Surprises Act, health care providers are required to provide patients who are uninsured or self-pay with a Good Faith Estimate of expected charges for medical services.

This Good Faith Estimate Policy explains your rights to receive an estimate and how CogniVita Center for Neuropsychology (“CogniVita,” “we,” “us,” or “our”) complies with this requirement.

Who Is Entitled to a Good Faith Estimate

You have the right to receive a Good Faith Estimate if you:
• Do not have health insurance, or
• Do not plan to submit a claim to your health insurance for services (self-pay)

What Is a Good Faith Estimate

A Good Faith Estimate is a written estimate of the expected charges for scheduled services. It includes:
• The expected cost of the evaluation or service
• Any reasonably anticipated items or services related to the evaluation
• The total estimated cost

Good Faith Estimates are not a bill and do not require payment.

When You Will Receive a Good Faith Estimate

CogniVita will provide a Good Faith Estimate:
• At least 1 business day before a scheduled service if the service is scheduled at least 3 business days in advance, or
• At least 3 business days before a scheduled service if the service is scheduled at least 10 business days in advance

You may also request a Good Faith Estimate at any time.

What the Estimate Does and Does Not Cover

A Good Faith Estimate:
• Reflects anticipated charges based on the information available at the time
• May change if your clinical needs change
• Does not guarantee specific outcomes or services

Actual charges may differ if additional or different services are provided based on clinical judgment.

Disputing Charges

If you receive a bill that is $400 or more above your Good Faith Estimate, you have the right to dispute the bill.

You may initiate a dispute through the U.S. Department of Health and Human Services (HHS) Patient-Provider Dispute Resolution (PPDR) process within 120 days of receiving the bill.

Information about the dispute process is available at:
https://www.cms.gov/nosurprises

Contact Information

If you have questions or would like to request a Good Faith Estimate, please contact:

CogniVita Center for Neuropsychology
13001 Founders Square Dr, Ste 200
Orlando, FL 32828
Phone: (321) 461-3202
Fax: (321) 204-6855
Email: admin@cognivitapsych.com