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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Our patients leave smiling

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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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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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My son had all wisdom teeth pulled out and the procedure went smoothly. Treatment plan was explained, staff ( from secretary to the Doctor) was friendly and knowledgeable. I recommend this clinic for dental care. Thank you!

Nikki M.

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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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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 surgeon, dental assistant and front desk staff. Thank you! *Updated 6/27/17

Pamela M.

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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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Awesome people! I had my reservations based on some yelp reviews [mostly concerning other issues other than the procedure itself]. So I went in with an open mind not really concerning myself with anything else other than getting my four wisdom tooth extracted. I came out pleasantly surprised at how professional and cautious the staff were. I was able to walk to my car unaided, did prescription run…

Bendu F.

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Always a thoughtful caring approach. You are informed and reminded how to take care of your self with respect to the surgery. A compassionate approach that is fully patient centered with a dentist who is fully present to your needs in the moment.Much appreciated.

A.Vincent

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I visited the Woodbridge office to have my wisdom teeth extracted. The experience was wonderful. The staff and Dr. Zadeh were professional and kind and did an excellent job. I would highly recommend them.

Anonymous

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I called for an appointment in Manassas and they were able to see me that afternoon.

Leonard J.

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Staff is professional and friendly which made my visit comfortable.

Brenda D.

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Everything was great! From beginning to end! Any questions I had and any concerns they were all addressed and they did everything they could to make me as comfortable as possible.

Nicole D.

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Courteous staff. Quick procedure. Painless

Trinity E.

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I had 4 teeth removed and was very nervous but they made me feel comfortable I will use them again. I have no pain today and it’s only been 24 hours.

Sherrie 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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I was overall impressed by the friendliness and professionalism of the staff from reception all through checkout. I was seen by Dr. Haron, he was extremely pleasant and knowledgeable. He answered all my questions and provided me with several options. He was very straight forward in regards to what each option will offer and the chances of success. I highly recommend NVOMSA.

Amer G.

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Had my wisdom teeth extracted yesterday and opted out of sedation. Needless to say, I was a bit nervous. But after 25 minutes I was checking out and felt great. I couldn’t talk much, but the entire process was fast and efficient. Now 24 hours later, I’m thinking I would be perfectly fine to go back to work tomorrow morning! I am very appreciative that I was recommended to this OMFS off…

Kassandra M.

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The surgeon and nurses were great. Very helpful in making the right decision and the after care was outstanding.

Brian R.

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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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