High Quality Treatment at an Affordable Price

Indiana Good Faith Estimate for Non-emergency Services:

In accordance with Indiana Code § 25-1-9.8-18, patients may request an estimate of their charges for non-emergency medical services provided at this facility.  The law requires that an estimate be provided within 5 business days of scheduling the nonemergency health service, unless the nonemergency health care service is scheduled to be performed by the practitioner within 5 business days of the date of the patient’s request.

This estimate is not binding and is not a guarantee of final billed charges.  The actual charges for services may vary based on the patient’s medical needs, and is only valid for 30 days.

If you have health insurance, your individual plan benefits will determine the final amount you owe.  We encourage you to contact your insurance company to address questions regarding your benefits.

If you would like to request a good faith estimate or have any questions regarding a good faith estimate please call our Patient Accounts Department 574-544-2200

Click here for PDF download

Federal Good Faith Estimate Information: 

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 one (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 Fait 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 Allied Physicians Surgery Center (574) 243-9700.

Click here for PDF download

Please call 574-544-2200 or click on the link below to request an estimate.

Good Faith Estimate

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