Your Right to a Good Faith Estimate

Effective Date: June 17, 2026

You have the right to receive a Good Faith Estimate explaining how much your scheduled healthcare may cost when you do not have insurance or do not plan to use insurance to pay for the service.

This right is provided under the federal No Surprises Act.

Who May Receive a Good Faith Estimate?

You may qualify for a Good Faith Estimate if:

  • You do not have health insurance
  • You have insurance but do not intend to submit the service to your health plan
  • You plan to pay for the service yourself
  • You request an estimate before scheduling
  • You schedule a healthcare service sufficiently in advance

This notice may apply even though Elysian Medspa & Rejuvenation Center accepts insurance.

When Will an Estimate Be Provided?

Under current federal requirements:

  • If a service is scheduled 3 to 9 business days in advance, the estimate generally must be provided within 1 business day after scheduling
  • If a service is scheduled at least 10 business days in advance, the estimate generally must be provided within 3 business days after scheduling
  • If you request an estimate before scheduling, it generally must be provided within 3 business days after the request

A federal Good Faith Estimate may not be required when a service is scheduled fewer than 3 business days in advance, although you may still ask us for available pricing information.

What Will the Estimate Include?

A Good Faith Estimate will include information required by applicable law, which may include:

  • Your identifying information
  • A description of the scheduled or requested service
  • The expected date or date range
  • Applicable diagnosis or service codes when required
  • An itemized list of reasonably expected charges
  • The provider or facility expected to furnish the listed services
  • Required disclaimers and dispute information

The estimate may address services reasonably expected to be provided by Elysian Medspa & Rejuvenation Center.

Services from outside laboratories, pharmacies, imaging facilities, specialists, hospitals, or other independent providers may require a separate estimate.

An Estimate Is Not a Guarantee

A Good Faith Estimate is based on information available when the estimate is prepared.

Actual charges may differ when:

  • Your care needs change
  • Additional evaluation is necessary
  • Unexpected findings occur
  • You request additional services
  • A provider recommends a different treatment
  • Medication, laboratory, product, or supply needs change
  • Another provider or facility participates in care
  • The planned service is postponed or modified

A Good Faith Estimate is not a diagnosis, treatment recommendation, guarantee of eligibility, or contract requiring a provider to perform a service.

Insurance Estimates Are Different

A Good Faith Estimate is generally intended for uninsured or self-pay patients.

If you plan to use insurance, your health plan determines:

  • Coverage
  • Medical necessity
  • Network status
  • Deductible
  • Copayment
  • Coinsurance
  • Authorization requirements
  • Final patient responsibility

Insurance verification and estimates are not guarantees of payment.

Contact your health plan for the most current benefit information.

Save Your Estimate

Keep a copy of your Good Faith Estimate.

You may need it to:

  • Compare the estimate with your bill
  • Discuss a billing concern
  • Request correction of an error
  • Use the federal patient-provider dispute process

If Your Bill Is Higher Than the Estimate

Contact Elysian Medspa & Rejuvenation Center if a bill appears inconsistent with your estimate.

We may be able to:

  • Explain the charges
  • Correct an error
  • Review whether services changed
  • Discuss available payment options
  • Provide additional documentation

Under current federal rules, you may be eligible to begin a patient-provider dispute resolution process if the billed charges from a provider or facility are at least $400 more than the amount listed for that provider or facility on the Good Faith Estimate.

The dispute generally must be started within 120 calendar days of the date on the original bill.

An independent dispute-resolution entity will review the information and determine the appropriate payment amount under applicable federal rules.

Starting a dispute does not prevent you from contacting us directly to discuss the bill.

How to Request an Estimate

To request a Good Faith Estimate, contact:

Elysian Medspa & Rejuvenation Center
6280 Shadeland Ave., Suite A
Indianapolis, IN 46220
Phone: (317) 526-5090
Email: info@elysianmedirejuv.com

Please provide:

  • Your name
  • Contact information
  • The service you are considering
  • Whether you are uninsured or do not plan to use insurance
  • The anticipated appointment date, if known

Do not include unnecessary sensitive medical information in ordinary email.

Questions About Federal Rights

Additional information about Good Faith Estimates and patient-provider dispute resolution is available from the Centers for Medicare & Medicaid Services.

This notice is intended to summarize current rights. Applicable law and federal procedures control if they differ from this summary.