Federal CMS standard notice — provided to you under the No Surprises Act (Public Health Service Act § 2799B-6; 45 C.F.R. §§ 149.610 & 149.620). If you don't have insurance or you are not planning to use insurance to pay for health care services, you have the right to receive a written estimate of the total expected cost of your care.
You have the right to receive a Good Faith Estimate explaining how much your care will cost
- 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 1 business day before your medical service or item. You can also ask your provider, and any other provider you choose, for a Good Faith 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 a 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 the No Surprises Help Desk at 1-800-985-3059.
When Rooted Health will provide your estimate
- Service scheduled 3+ business days out: we deliver your Good Faith Estimate within 1 business day of scheduling.
- Service scheduled 10+ business days out: we deliver your Good Faith Estimate within 3 business days of scheduling.
- Patient request (no service scheduled): we deliver your Good Faith Estimate within 3 business days of your request.
- Estimates are delivered electronically through your patient portal or, on request, by paper or PDF email. The estimate is valid for the date listed; new estimates are issued if the scope of service changes.
What your Good Faith Estimate will include
Each Good Faith Estimate from Rooted Health will include, at minimum, the items required by 45 C.F.R. § 149.610(c):
- Your name and date of birth.
- A clear description of the primary item or service to be furnished and the scheduled date (if applicable).
- An itemized list of items and services reasonably expected to be furnished, grouped by provider or facility.
- For each item: the applicable diagnosis code, expected service code, and the expected charge.
- Name, National Provider Identifier (NPI), and Tax Identification Number (TIN) of each provider or facility represented in the estimate, and the state(s) and office or facility location(s) where the items or services are expected to be furnished.
- A list of items or services the provider anticipates will require separate scheduling and that are expected to occur before or following the primary item or service.
- The disclaimers required by CMS, including that the estimate is not a contract and does not require the patient to obtain the items or services from Rooted Health.
What is and is not included
- Included: Rooted Health membership fees, in-clinic and telehealth visits, in-house procedures (e.g., injections, IV therapy, aesthetics), point-of-care testing, and dispensed medications when known at the time of scheduling.
- Not included: charges from other providers or facilities Rooted Health does not control — for example, outside laboratories, imaging centers, hospitals, pharmacies that fill external prescriptions, specialists, ambulance services, and any item or service that is not reasonably foreseeable at the time the estimate is issued. You may request a separate Good Faith Estimate directly from those providers.
- Emergency services: Good Faith Estimates are not required for emergency items or services. Call 911 or go to the nearest emergency department for any emergency.
Insurance status — your choice
Good Faith Estimates apply to patients who are uninsured or who are insured but elect not to submit a claimfor the scheduled item or service. Rooted Health is a direct primary care practice and is not in-network with any insurance plan; we do not bill commercial insurance, Medicare, Medicaid, or TRICARE for membership-based care. Membership and direct-pay services are self-pay by design, and the Good Faith Estimate process applies to them. See our HIPAA Notice for how your information is used.
Patient-Provider Dispute Resolution (PPDR)
If your final billed charges from a single provider are at least $400 more than that provider's Good Faith Estimate, you may initiate a Patient-Provider Dispute Resolution with the U.S. Department of Health & Human Services within 120 calendar days of receiving the original bill. To start a dispute:
- Visit cms.gov/nosurprises/consumers or call 1-800-985-3059.
- You will need a copy of your Good Faith Estimate, the bill in question, and your contact information.
- The administrative fee for the patient is currently $25 (subject to CMS adjustment) and is refundable if the dispute is resolved in your favor.
- Initiating a dispute will not adversely affect the quality of care you receive from Rooted Health.
How to request a Good Faith Estimate from Rooted Health
- Email: billing@rootedhealthmember.com
- Phone: contact our office in Conway, Arkansas during business hours.
- Patient portal: send a secure message requesting an estimate; we will reply with a written PDF.
Required disclaimers
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health-care needs for an item or service. The estimate is based on information known at the time it was created and 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 the bill if it is at least $400 more than the estimate.
This Good Faith Estimate is not a contract. It does not obligate you to obtain the items or services listed from Rooted Health.
Effective date
This notice is effective May 13, 2026 and supersedes any prior version.