Patient rights and notices

Notice of nondiscrimination

LivingWell Clinic PLLC complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. LivingWell Clinic does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

LivingWell Clinic:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats and others).
• Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services, please call us at 630-242-2455.

If you believe that LivingWell Clinic has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with us in person, by mail, by fax or by email at 473 West Army Trail Road, Suite 105, Bloomingdale, IL 60108; phone 630-242-2455; fax 630-242-2435; email info@livingwellclinic247.com.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal at ocrportal.hhs.gov, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at hhs.gov/ocr/office/file.

Your right to a Good Faith Estimate

You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

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

This applies to our self-pay services, including cash-pay eye exams and our self-pay monthly weight management plan. Ask our team for your estimate.