NO SURPRISES ACT DISCLOSURE

Last Updated: July 18, 2026

1. Your Right to a Good Faith Estimate

Under the No Surprises Act (45 C.F.R. § 149.610), if you do not have dental insurance, or if you have insurance but choose not to use it for a scheduled item or service, you have the right to receive a Good Faith Estimate of the expected charges for that item or service before it is furnished. Cal American Dental provides Good Faith Estimates to uninsured and self-pay patients, including patients who choose to pay out of pocket rather than use their insurance coverage.

2. Timing of the Estimate

If your item or service is scheduled at least three business days in advance, you will receive your Good Faith Estimate no later than one business day after scheduling. If your item or service is scheduled at least ten business days in advance, or if you request an estimate without scheduling an item or service, you will receive your Good Faith Estimate no later than three business days after the date of the request or scheduling, as applicable.

3. Our Estimate Process

Before your consultation, we provide a printed estimate covering the examination and any necessary x-rays. This estimate is given to you in our lobby prior to your consultation appointment. Following your consultation, once your dentist has determined the treatment you need, we provide a second printed estimate reflecting the actual costs of the recommended treatment. This second estimate is provided before you leave our office and before any treatment is scheduled. Treatment forms and consent documents are reviewed and signed before any dental services are performed.

4. Contents of the Estimate

Your Good Faith Estimate will include the expected charges for the specific items and services reasonably expected to be provided, along with the associated diagnosis, where applicable. The estimate is based on the information available to us at the time it is prepared and may change if your treatment plan changes.

5. Your Right to Dispute a Higher Bill

If the amount you are billed is substantially higher than the amount reflected in your Good Faith Estimate, specifically, at least $400 more for any provider or service included in the estimate, you have the right to dispute the bill through the Patient-Provider Dispute Resolution (PPDR) process established by the U.S. Department of Health and Human Services. You must initiate a dispute within 120 calendar days of receiving the original bill. More information about this process, including how to initiate a dispute, is available at www.cms.gov/nosurprises or by calling 1-800-985-3059.

6. Billing Questions

If you have questions about a Good Faith Estimate you received, or about your bill, please contact our office:

Phone: (909) 620-4600

Email: calamericandental@gmail.com

7. Provider Information

Dr. Ricardo F. Jara, DDS, FICOI

National Provider Identifier (NPI): 1619492469

A copy of this disclosure is available at our office and on our website.