No Surprises Act Disclosure

Effective Date: January 1, 2022

Your Rights Against Surprise Medical Bills

Under the No Surprises Act, you have protections against unexpected medical bills in certain situations. This notice explains those rights.

Emergency Services

If you have a medical emergency, you have the right to receive emergency services from any provider or facility, even if they are not in your health plan's network, without obtaining prior authorization and without paying more than your in-network cost-sharing amount.

Non-Emergency Services at In-Network Facilities

When you receive non-emergency care at an in-network facility, you have the right to be protected from surprise billing if out-of-network providers are involved in your care without your knowledge. In these cases, out-of-network providers may not bill you more than your in-network cost-sharing amount, unless you provide informed written consent and waive your protections.

Out-of-Network Provider Disclosures

If Waterfront Family Dental is out of network with your insurance plan, we are required to provide you with a notice explaining your rights before you receive non-emergency care. You have the right to receive a good faith cost estimate before scheduled services.

Good Faith Estimates

You have the right to receive a "Good Faith Estimate" explaining the expected cost of any non-emergency items or services. This estimate must be provided in advance of your scheduled service. If your actual bill exceeds the Good Faith Estimate by more than $400, you may be able to dispute the bill.

To request a Good Faith Estimate or for questions about your estimate, contact us before your scheduled appointment.

Questions and Complaints

For questions about your rights or to file a complaint about a violation of these protections, contact: