Good Faith Estimate Notice
Your Right to a Good Faith Estimate
No Surprises Act • Effective January 1, 2022 • 42 U.S.C. § 300gg-136
What Is a Good Faith Estimate?
A Good Faith Estimate (GFE) is a written document that tells you, in advance, the expected cost of healthcare items and services you are scheduled to receive. It is provided to you free of charge and must be delivered before your appointment.
The estimate includes an itemized list of services, applicable procedure codes, and the expected charge for each service. It is not a final bill and not a contract — actual costs may differ based on what is ultimately provided during your visit.
What Your Estimate Will Include
Clinic Services
The expected cost of your telehealth consultation, including the applicable visit type and procedure code.
Itemized Breakdown
Each service listed separately with its CPT code and individual expected charge.
Appointment Details
Your scheduled date and service location (telehealth — HIPAA-compliant video platform).
Not Included
Lab fees, imaging fees, and specialist charges are billed directly by those independent providers — not this clinic.
A Note on Labs & Imaging
Direct Pay Virtual Clinic may order laboratory tests or imaging studies (X-rays, MRIs, CT scans, ultrasounds, etc.) as part of your care. These costs are not included in your Good Faith Estimate from this clinic. Laboratories and imaging facilities are independent, third-party providers that bill you directly. We have no financial interest in those charges and no control over their pricing.
We encourage you to contact your chosen laboratory or imaging facility directly to request their own Good Faith Estimate before scheduling those services.
When You Will Receive Your Estimate
Federal law requires that we provide your Good Faith Estimate on the following schedule:
- At least 1 business day before your appointment, if scheduled 3–9 business days in advance
- At least 3 business days before your appointment, if scheduled 10 or more business days in advance
- Within 3 business days of your request, if you ask for an estimate before scheduling
Your Good Faith Estimate will be delivered electronically through your patient intake process. You may also request a paper copy at any time by contacting us at info@directpayvirtualclinic.org.
Your Right to Dispute a Bill
Important — The $400 Rule
If you receive a final bill that is $400 or more above the total shown on your Good Faith Estimate, you have the right to dispute that bill through the federal Patient-Provider Dispute Resolution process.
Keep a copy of your Good Faith Estimate. You will need it if you choose to file a dispute.
How to File a Dispute
- You must initiate the dispute within 120 calendar days of the date on your bill
- There is a $25 administrative fee to initiate the dispute resolution process
- An independent dispute resolution entity selected by CMS will review the documentation and make a binding determination
- Filing a dispute will not affect the quality of care you receive from this clinic
Where to File
- Online: www.cms.gov/nosurprises
- Phone: 1-800-985-3059 (CMS No Surprises Help Desk)
Our Direct Pay Model & Pricing
Direct Pay Virtual Clinic operates on a transparent, direct-pay (cash-pay) model. We do not accept or bill health insurance of any kind, including private insurance, Medicare, or Medicaid. All fees are due at the time of service.
Our current fee schedule is available on our Pricing page. Fees are subject to change; the price confirmed in your personalized Good Faith Estimate — delivered before your visit — reflects the fee in effect at the time of your appointment.
If you have an HSA or FSA, fees paid to this clinic may be eligible for reimbursement subject to IRS rules and your account terms. We can provide a superbill (itemized receipt with procedure and diagnosis codes) upon request for potential self-submission to your private insurer; however, reimbursement is not guaranteed.
Request a Good Faith Estimate
You may request a Good Faith Estimate at any time — even before scheduling. We will respond within 3 business days of your request.
- Email: info@directpayvirtualclinic.org
- Website: Contact Form
Legal Reference
This notice is provided in compliance with the No Surprises Act (Pub. L. 116-260, Division BB, Title I), codified at 42 U.S.C. § 300gg-136 and implementing regulations at 45 C.F.R. § 149.610. Additional Minnesota price transparency requirements are governed by Minn. Stat. § 62J.81.
For more information about your rights under the No Surprises Act, visit www.cms.gov/nosurprises or call the CMS No Surprises Help Desk at 1-800-985-3059.