Good Faith Estimate Notice 

NOTICE OF SURPRISE BILLING PROTECTION RIGHTS  

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.  Under the law, i.e. “The No Surprises Act,” health care providers need to give patients who don’t have insurance, or who are not using their insurance such as in-network benefits, an estimate of the bill for medical items and services.  You are receiving this notice because either you don’t have insurance, or the provider is out-of-network.  Please note your right to the following:  

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services listed.  It is an estimate only. It isn’t an offer or a contract.  It does not include any information about your health plan such as what it may cover, reimbursement, or if the amount will count towards your deductible or out-of-pocket limit.   . 

• 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 have the right to dispute the bill.    

You may contact the health care provider to let them know the billed charges are higher than the Good Faith Estimate.  You can ask them to update the bill to match the Good Faith Estimate, ask 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 (HHS).  If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.  

There is a $25 fee to use the dispute process.  If the agency reviewing your dispute agrees with you, you will have to pay the prices on this Good Faith Estimate.  If the agency disagrees with you and agrees with the health care 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.  

• Make sure to save a copy or take a picture of your Good Faith Estimate, and keep it in a safe place.  You may need it if you are billed a higher amount.     

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