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