Good Faith Estimate Notice
Your Right to Receive a Good Faith Estimate of Expected Charges
Effective Date: March 31, 2026
Last Updated: March 31, 2026
YOUR RIGHTS UNDER THE NO SURPRISES ACT
At New Viva MD Weight Loss, we believe patients should understand the expected costs of their healthcare services before receiving treatment.
Under federal law, patients who do not have health insurance or who choose not to use their health insurance for certain services have the right to receive a Good Faith Estimate (GFE) explaining the anticipated cost of their medical care.
This notice explains your rights under the No Surprises Act, effective January 1, 2022.
WHAT IS A GOOD FAITH ESTIMATE?
A Good Faith Estimate is a written estimate of the expected charges for healthcare items and services provided by New Viva MD Weight Loss.
The estimate helps you understand potential healthcare costs before receiving services and allows you to make informed decisions about your care.
The estimate is based on information known at the time it is prepared and may not include unexpected costs that arise during treatment.
WHO IS ELIGIBLE TO RECEIVE A GOOD FAITH ESTIMATE?
You are entitled to receive a Good Faith Estimate if:
- You do not have health insurance; or
- You choose not to use your health insurance for a particular service; or
- You are considered a self-pay patient.
WHAT COSTS MAY BE INCLUDED?
A Good Faith Estimate may include expected charges related to:
- Office visits
- Medical weight loss consultations
- Hormone optimization consultations
- Concierge medicine services
- Laboratory testing
- Diagnostic services
- Prescription medications administered in-office
- Medical procedures
- Body composition analysis
- Wellness services
- Follow-up visits
The estimate may also include reasonably expected charges from other providers involved in your care when applicable.
WHEN WILL I RECEIVE MY GOOD FAITH ESTIMATE?
You have the right to receive a written Good Faith Estimate:
If Scheduled at Least 10 Business Days in Advance
You will receive your estimate within 3 business days after scheduling.
If Scheduled Between 3 and 9 Business Days in Advance
You will receive your estimate within 1 business day after scheduling.
Upon Request
You may request a Good Faith Estimate before scheduling any service.
New Viva MD Weight Loss will provide the estimate within the timeframe required by federal law.
WHAT IF MY FINAL BILL IS HIGHER THAN THE ESTIMATE?
If you receive a bill that is at least $400 more than the Good Faith Estimate you received, you have the right to dispute the charges through the federal patient-provider dispute resolution process.
Federal law provides protections to help ensure healthcare costs remain transparent and predictable.
HOW DO I START A DISPUTE?
If your final bill exceeds your Good Faith Estimate by $400 or more, you may initiate a dispute through the U.S. Department of Health and Human Services (HHS).
Additional information regarding the dispute process is available through the Centers for Medicare & Medicaid Services (CMS).
IMPORTANT REMINDERS
- Request a Good Faith Estimate before scheduling services whenever possible.
- Review your estimate carefully.
- Ask questions if anything is unclear.
- Save a copy of your Good Faith Estimate for your records.
- Keep copies of bills, invoices, and related healthcare documentation.
QUESTIONS ABOUT YOUR ESTIMATE?
If you have questions regarding your Good Faith Estimate or expected healthcare costs, please contact our office.
New Viva MD Weight Loss
2390 West Ray Road, Suite 1
Chandler, Arizona 85224
Phone: (480) 331-4316
Email: drs@newvivamd.com
ADDITIONAL INFORMATION
For more information regarding your rights under the No Surprises Act and Good Faith Estimates, visit:
https://www.cms.gov/nosurprises
or call:
1-800-MEDICARE (1-800-633-4227)
New Viva MD Weight Loss is committed to providing transparent pricing and helping patients understand the expected costs of their healthcare services.