Effective date: September 22, 2026
Last reviewed: September 22, 2026
This notice explains certain rights you may have under the federal No Surprises Act, including the right of uninsured and self-pay individuals to receive a Good Faith Estimate of expected healthcare charges and protections against certain unexpected out-of-network medical bills.
Your specific rights depend on your insurance status, the type of healthcare service, where the service is provided, and the healthcare professionals or facilities involved.
Your Right to a Good Faith Estimate
If you do not have health insurance or do not plan to submit a claim to your health insurance plan for a scheduled healthcare item or service, you generally have the right to receive a Good Faith Estimate explaining the expected cost of your care.
This protection applies to individuals who are:
- Not enrolled in a health insurance plan or other health coverage
- Enrolled in coverage but do not intend to submit a claim for the scheduled item or service
- Choosing to pay for the item or service without using available health coverage
These individuals are commonly described as “uninsured” or “self-pay” individuals.
What a Good Faith Estimate Includes
A Good Faith Estimate should identify the healthcare items and services that are reasonably expected to be provided as part of the scheduled care or requested service.
Depending on the circumstances, the estimate may include:
- The patient’s name and date of birth
- A description of the primary scheduled service
- Other items or services reasonably expected to be provided
- Expected diagnosis or service codes when applicable
- The provider’s or facility’s identifying information
- Expected charges for the listed items and services
- Required federal disclaimers and dispute information
A Good Faith Estimate is based on information known when the estimate is prepared. It is not a contract or guarantee of the final amount charged.
Actual charges may differ if your needs change, additional services become medically necessary, information provided during scheduling was incomplete, or another circumstance affects the care you receive.
When You Should Receive an Estimate
If you request a Good Faith Estimate before scheduling care, the estimate will generally be provided within three business days after the request.
If an item or service is scheduled at least 10 business days in advance, the estimate will generally be provided within three business days after scheduling.
If an item or service is scheduled between three and nine business days in advance, the estimate will generally be provided within one business day after scheduling.
Federal Good Faith Estimate requirements may not require an estimate when a service is scheduled fewer than three business days in advance. You may still ask Welgen One for available pricing information.
If a recurring service or continuing course of care is expected, the estimate may cover a defined period as permitted by law. An updated estimate may be issued when the expected services or charges materially change.
Requesting a Good Faith Estimate From Welgen One
You may request a written Good Faith Estimate before scheduling an item or service or at the time you schedule it.
To request an estimate, contact Welgen One and state that you are uninsured, intend to self-pay, or do not plan to submit a claim to your health insurance plan.
Email: info@welgenone.com
Telephone: 770-212-0015
Toll-free: 866-411-9354
Please provide enough information for us to identify the service you are considering. Do not submit detailed medical information through ordinary email unless Welgen One has specifically instructed you to use that method.
Keep a copy of your Good Faith Estimate. You may need it if you later question or dispute a bill.
Services From Other Providers or Facilities
Your care may involve services furnished by an independent laboratory, imaging center, pharmacy, healthcare professional, facility, technology provider, or other organization.
An estimate from Welgen One may not include every charge from an independent provider or facility unless those charges are required to be included and the necessary information is available.
You may contact each independent provider or facility directly to request information about its expected charges and network participation.
If Your Bill Is Higher Than the Good Faith Estimate
If you receive a bill that is at least $400 more than the total 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.
To qualify, you generally must start the dispute process within 120 calendar days of the date shown on the original bill.
During the dispute process, an independent dispute-resolution entity will review the Good Faith Estimate, the bill, and information submitted by you and the provider or facility.
Eligibility for the dispute process is determined under federal law. Submitting a dispute does not guarantee that the billed amount will be reduced.
For current instructions or to begin a dispute, visit:
https://www.cms.gov/medical-bill-rights/help/dispute-a-bill
You may also visit the federal Patient-Provider Dispute Resolution portal:
https://nsa-idr.cms.gov/billdisputes/s/
Do not delay filing a dispute while attempting to resolve the bill directly with Welgen One or another provider. The federal filing deadline may continue to run while the parties communicate.
Protections Against Surprise Medical Bills
When you receive emergency care or are treated by an out-of-network provider at an in-network hospital, hospital outpatient department, or ambulatory surgical center, you may be protected from unexpected out-of-network bills.
Federal surprise-billing protections generally apply to:
- Most emergency services provided by an out-of-network provider or emergency facility
- Certain non-emergency services provided by an out-of-network provider at an in-network hospital, hospital outpatient department, or ambulatory surgical center
- Covered air-ambulance services provided by an out-of-network air-ambulance provider
These protections generally do not apply to ground ambulance services under current federal law, although state law or other protections may apply.
The protections may also differ for Medicare, Medicaid, TRICARE, Indian Health Service, Veterans Affairs programs, or other government coverage because those programs have separate billing rules.
Emergency Services
If you receive covered emergency services from an out-of-network provider or facility, the provider or facility generally may not bill you more than your plan’s in-network cost-sharing amount for protected services.
Protected emergency services generally must be covered:
- Without prior authorization
- Regardless of whether the provider or emergency facility is in your plan’s network
- Without imposing out-of-network cost sharing that exceeds the applicable in-network amount
You generally cannot be balance billed for protected emergency services.
Certain Services at an In-Network Facility
When you receive non-emergency care at an in-network hospital, hospital outpatient department, or ambulatory surgical center, some professionals involved in your care may be out of network.
For covered services protected by federal law, those out-of-network professionals generally may not bill you more than the applicable in-network cost-sharing amount.
Federal law provides particularly strong protections for certain ancillary services, which may include:
- Emergency medicine
- Anesthesiology
- Pathology
- Radiology
- Neonatology
- Services provided by assistant surgeons, hospitalists, and intensivists
- Diagnostic services, including certain radiology and laboratory services
- Services provided when no in-network professional is available
- Services resulting from unforeseen urgent medical needs
For these protected services, you generally cannot be asked to waive federal balance-billing protections.
Notice and Consent for Certain Out-of-Network Services
For some non-emergency services, an out-of-network provider may ask you to sign a federal notice and consent form before providing care.
Signing a valid notice and consent form may waive certain balance-billing protections and could result in higher out-of-network charges.
You are not required to waive your protections merely because a provider presents a notice and consent form. When permitted, you may choose an available in-network provider instead.
A federal notice and consent form cannot be used to waive protections for certain ancillary services, unforeseen urgent medical needs, or other services for which waiver is prohibited.
Your Rights When Federal Surprise-Billing Protections Apply
When a service is protected by the No Surprises Act:
- You are generally responsible only for applicable in-network cost sharing.
- Your health plan should count your cost-sharing amount toward your in-network deductible and out-of-pocket limit.
- An out-of-network provider or facility generally may not balance bill you for the protected amount.
- You generally are not responsible for resolving payment disputes between the provider and your health plan.
- You may report suspected violations to the federal government or the appropriate state agency.
These protections do not eliminate your responsibility to pay legitimate deductibles, copayments, coinsurance, noncovered services, or other amounts properly assigned to you under your health plan.
Confirming Insurance Coverage
Participation by Welgen One or another healthcare professional with an insurance company does not guarantee that every service is covered under your specific plan.
Before receiving non-emergency services, you should contact your health plan to confirm:
- Whether the provider and service location are in network
- Whether the service is covered
- Whether prior authorization is required
- Your remaining deductible
- Your expected copayment or coinsurance
- Whether laboratory, imaging, technology, or other associated providers are in network
Information provided by Welgen One concerning coverage or expected patient responsibility is an estimate and is not a guarantee of payment by your insurance plan.
If You Believe You Were Improperly Billed
If you believe you received an improper surprise bill or were charged more than permitted:
- Keep copies of the bill, Explanation of Benefits, Good Faith Estimate, notices, consent forms, and related communications.
- Contact the provider or facility shown on the bill.
- Contact your health insurance plan using the telephone number on your insurance card.
- Contact the federal No Surprises Help Desk or the appropriate state regulatory agency.
Federal No Surprises Help Desk: 1-800-985-3059
Online information: https://www.cms.gov/nosurprises/consumers
Calling the federal Help Desk is free. Assistance is available in multiple languages.
Georgia Consumer Assistance
Georgia residents may also contact the Georgia Office of Commissioner of Insurance and Safety Fire regarding insurance questions or possible violations of applicable state insurance laws.
Website: https://oci.georgia.gov/
State law may provide protections in addition to federal law. The federal No Surprises Help Desk or the Georgia insurance regulator can help determine which protections may apply.
Important Limitations
This webpage provides general information about patient billing protections. It is not a substitute for the official Good Faith Estimate prepared for your care, your insurance policy, an Explanation of Benefits, or advice from an insurer, regulator, or attorney.
Not every Welgen One service will necessarily fall within every No Surprises Act provision described on this page. The applicable protection depends on the type of service, insurance coverage, provider network status, service location, and other facts.
Nothing in this notice waives a protection available to you under federal or state law.
Contact Welgen One
For questions about a Welgen One estimate or bill, contact:
Welgen Global Enterprises, LLC
Doing business as Welgen One
309 East Paces Ferry Road NE, Suite 400
Atlanta, Georgia 30305
United States
Email: info@welgenone.com
Telephone: 770-212-0015
Toll-free: 866-411-9354
Website: https://welgenone.com