Notice of Your Right to Receive a Good Faith Estimate

Forge is a self-pay practice and does not submit claims to health insurance for Forge services. Accordingly, Forge treats every patient as a self-pay or no-claim patient for its own charges.

If you do not have applicable health coverage, or you have coverage but no claim will be submitted for a particular item or service, you have the right to receive a written Good Faith Estimate of the expected charges for that care.

You may request a Good Faith Estimate before scheduling an item or service. If you schedule care at least three business days in advance, Forge Men’s Health PLLC will provide a Good Faith Estimate within the time required by federal law.

A Good Faith Estimate describes the items and services reasonably expected based on the information known when the estimate is prepared. Forge provides its estimate through Practice Better in a form that can be saved and printed. Charges billed to you by Forge, including any laboratory panel purchased through Forge, are included in Forge’s Good Faith Estimate. When an outside laboratory, pharmacy, or other provider bills you directly, that organization is responsible for pricing information about its own charge.

Florida law also gives you the right to receive, on request and before treatment, a reasonable estimate of charges for medical services. Before a planned non-emergency service, Forge will provide uninsured and self-pay patients with a reasonable estimate of charges together with information about any discount or charity-care policy for which they may be eligible.

Forge does not currently offer a charity-care or income-based discount program. If that changes, this notice will be updated.

• If care is scheduled 3–9 business days in advance, the estimate generally must be provided within one business day after scheduling.
• If care is scheduled 10 or more business days in advance, the estimate generally must be provided within three business days after scheduling.
• If you request an estimate before scheduling, it generally must be provided within three business days after the request.

The estimate will be provided on paper or electronically, based on your requested method of delivery. An electronic estimate will be provided in a form that you can save and print.

This notice explains your rights. It is not a patient-specific Good Faith Estimate. Prices published elsewhere on this website are general prices and do not replace the written estimate issued for your anticipated care.

A Good Faith Estimate is not a contract and does not require you to obtain the listed items or services from Forge or any other identified provider or facility.

If the total billed charges from a particular provider or facility are at least $400 more than the expected charges listed for that provider or facility in your Good Faith Estimate, you may be eligible to use the federal patient-provider dispute resolution process.

A dispute generally must be started within 120 calendar days after you receive the initial bill. Starting a dispute will not adversely affect the quality of care you receive.

Keep a copy of your Good Faith Estimate and any bills you receive.

To request a Good Faith Estimate from Forge Men’s Health PLLC, email info@forgemh.com. Existing patients may also make a request through Forge’s secure patient communication system.

General questions may be sent to info@forgemh.com. Do not include medical information in ordinary email.

For more information, visit cms.gov/medical-bill-rights or call the federal No Surprises Help Desk at 1-800-985-3059.

If you need this notice in another language or an accessible format, email Forge at info@forgemh.com.