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 nonemergency 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
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs. The estimate is based on information known at the time the estimate was created.
There may be additional services that we recommend as part of the course of care that mut be scheduled or requested separately and are not reflected in this Good Faith Estimate.
The information provided in this Good Faith Estimate is only an estimate of items or services reasonably expected to be furnished at the time this Good Faith Estimate was given. Actual items, services, or charges may differ from the Good Faith Estimate.
You have the right to initiate the patient-provider dispute resolution process if the actual billed charges are $400 more than the expected charges included in the Good Faith Estimate and the dispute is initiated within 120 days after the date of the bill for the items or services. To start the process, you may contact us at the phone number or address listed above to let us know the billed charges are at least $400 or higher that the Good Faith Estimate. You can ask us to update the bill to match the Good Faith Estimate, as us to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services within 120 calendar days (about 4 months) of the date on the orginal bill. There is a $25 fee to use the dispute process. If the agency disgrees with you, and agrees with the healthcare provider, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 1 (800) 985-3059.
This Good Faith Estimate is not a contract and does not require you to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.
Keep a copy of the Good Faith Estimate, you may need it if you are billed a higher amount.