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 non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, mental health therapy, 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 information on how to initiate the patient- provider dispute resolution process, visit www.cms.gov/nosurprises or call (800) 368- 1019. Initiation of the patient-provider dispute resolution process will not adversely affect the quality of healthcare services provided to you.

This GFE is not a contract and does not require you to participate in any of the services identified in the GFE, nor does it obligate me to provide services to you.