Good Faith Estimate
Good Faith Estimate for
Health Care Items and Services
Good Faith Estimate for Health Care Items and Services
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 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 non-emergency items or services. This Good Faith Estimate shows the costs of services that are reasonably expected for your health care needs.
The estimate is based on information known at the time the estimate was created. This estimate does not include any unknown or unexpected costs that may arise once the service begins.
Make sure your healthcare provider gives you a Good Faith Estimate in writing at least one (1) business day before your medical service or item. 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. To do this, please contact our office at email@example.com.
If this is not resolved satisfactorily, you can start a dispute resolution with the U.S. Department of Health & Human Services (HHS). You must start this process within 120 calendar days of the date of the original bill. There is a $25 fee to use the HHS dispute process. If the agency agrees with you, you will pay the amount on this estimate. If the agency disagrees with you, you will pay the higher billed amount to the health care provider. To learn more or start the process, go to: www.cms.gov/nosurprises.
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.