Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost

Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the healthcare provider or facility gives you a Good Faith Estimate in writing within 3-business days after you ask.
  • If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.

Three Convenient Locations to Serve You

We have three locations in the Northern Virginia area including Annandale, Manassas and Woodbridge. To find an office near you, click the link below.

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This letter is to follow-up with you sharing my experience before and after regarding being diagnosed at your office with Arthritis and describing pain in my jaw, ear, and neck pain etc. In the course of about a year, I went to urgent care, ear and throat specialists, twice to a dentist, two times to a primary care provider, had a sleep apnea test, hearing test and finally coming to your practice.…

Cecilia G.

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Excellent staff who were courteous and knowledgeable.

Anonymous

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Dr. Jackson and her staffs are one of the best professionals I’ve met so far. They were ‘EXTREMELY’ patient and kind during the whole procedure. I highly recommend them.

Jacob K.

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Dr. Zadeh is not only a very qualified oral surgeon, he is a very warm and easy to communicate with kind of person. I had a lower canine that had been root-canaled some time ago and ended up having a painful infection. He took out my infected tooth like he pulled out a needle from a butter, not feeling any pain at all. He then placed an imediate implant. He is very efficient in using his time and…

Zufan H.

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Everyone in the office was very friendly and informative. Dr. Zadeh is a wonderful oral surgeon. He puts you at ease and explains everything very well. My recovery went exceedingly well, which was a testament to his expertise.

Anthony W.

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Very friendly and professional staff. Did an excellent job with a tooth extraction I needed.

Michael S.

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I felt very confident that I was in a professional environment and that my doctor new exactly what he was doing.

Anonymous

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Great staff

Anonymous

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Referred here after my first dentist wasn’t comfortable taking out my lower wisdoms. They fit me in the schedule same day and before I knew it, I was done and recovering.

Te-von H.

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The doctor was very nice and very concern about me.

Rose C.

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Dr. Jackson was extremely professional, patient, informative as well as friendly and enjoyable. She explained everything in great detail before my procedure. My personal dentist, Dr. Jones, recommended her. I knew if Dr. Jones recommended her she had to be great. My procedure was exactly as she explained. Her assistant Rosemary was also wonderful. I highly recommend Dr. Jackson to anyone reading t…

Maria S.

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Excellent, attentive and very skillful

Christopher G.

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Staff is professional and friendly which made my visit comfortable.

Brenda D.

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Dr. Zadeh and his implant team did an excellent job with my two implants. They all worked to put me at ease which made the procedure stress free. Thank you very much!

Shelley G.

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Excellent service at a reasonable price. I had to have surgery right away, and they got me inside, got the surgery for much less than I expected to be charged and had an issue later when I got home. The Doctor called me herself, and followed up with me two more times to make sure everything was okay. There was very little pain and the swelling went down when they said it would, I highly recommend…

James M.

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It is my first time in this place I was treated with a professional the girls who are at the front all very kindly make it feel like at home very friendly nurses and doctors

Marta H.

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Professional staff who walked me through every phase of my tooth extraction with a calm and caring approach..

Veronica A.

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Dr Haron is very professional He and the staff took very good care of me. Dr went out of his way to make sure I was taken care of and not in any pain.

Catherine L.

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Unfortunately we had to be seen for an emergency situation. Dr. Haron was very thorough with informing us of what was to be expected. He was spot on with what happened and what he told us to expect. His calm, gentle demeanor was quite settling for us.

Anonymous

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Had not had a tooth pulled in about 50 years so really could not remember what to expect. Things went pretty smoothly I’m pleased to report. Was sorry to hear that BC/BS stopped covering tooth extractions in 2015! Glad to have the infected tooth out of my mouth…appreciate being taken by your practice on short notice.

Barbara B.

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