Good Faith Estimate

Notice of Right to Receive a Good Faith Estimate of Expected Charges Under the No Surprises Act

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

Under the law, healthcare providers need to give patients who don’t have insurance or who self-pay for their services an estimate of the bill for medical items and services.

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• You have the right to receive a Good Faith Estimate for the total expected cost of any non-

emergency items or services, including medical services.

• Ensure your healthcare provider gives you a Good Faith Estimate in writing at least one business

day before your services begin. You can also ask your healthcare 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 the U.S. Department of Health and Human Services (HHS) at 1-800-985-3059.