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Your Right to a Good Faith Estimate

Under the federal No Surprises Act · Effective April 22, 2026

You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost.

Under the law, healthcare providers need to give patients who don't have insurance or who are not using insurance an estimate of the expected charges for medical items and services.

What You're Entitled To

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
  • Make sure your healthcare provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service. You can also ask your healthcare provider for a Good Faith Estimate before you schedule a 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.

How Crescent Health Delivers Your Estimate

After you book an appointment, Crescent Health will send a written Good Faith Estimate by email. Our standard self-pay rate is a flat $59 per visit, which covers:

  • A live consultation with a licensed provider (audio call, with video if your provider determines it is needed)
  • Clinical assessment and medical advice
  • Prescription sent to your pharmacy, if clinically appropriate
  • Post-visit follow-up messaging

Items billed separately by third parties (not by Crescent Health) may include laboratory tests ordered during your visit and medications dispensed by your pharmacy.

Sample Good Faith Estimate

GOOD FAITH ESTIMATE

Provider: Syeda Fatima, MD — Crescent Community Care LLC

Provider Address: P.O. Box 3179, Lilburn, GA 30048

Patient: [Your Name]

Date of Estimate: [Date]

Expected Date of Service: [Appointment Date]

Item / Service: Telehealth consultation (expected CPT 99213 or 99214)

Expected Diagnosis: To be determined at visit

Expected Charges: $59.00

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your healthcare needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

How to Dispute a Bill

If you are billed for $400 or more above your Good Faith Estimate, you may start a dispute within 120 calendar days of receiving the bill. You must pay no more than the Good Faith Estimate amount until the dispute resolution process concludes.

To file a dispute:

Questions or Problems Receiving Your Estimate

For questions about your Good Faith Estimate, email us at admin@crescent-telemed.com or call (770) 923-2740.

For more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises.