No Surprises Act

Good Faith Estimate for Services

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, 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.

Please Note:

• There may be additional items or services the convening provider recommends as part of the course of care that must be scheduled or requested separately and are not included in the GFE.
• The information provided in the GFE at the time it is given to the individual is only an estimate regarding items or services reasonably expected to be furnished, and actual items, services, or charges may differ.
• The individual has the right to initiate the patient-provider dispute resolution process if the actual billed charges are substantially in excess of the expected charges included in the GFE.
• There is no penalty for requesting this estimate.
• This estimate is not a contract and does not require the individual to obtain the items or services from any of the providers or facilities identified.
• By going to an out-of-network or not using insurance one acknowledges the cost will be different from if your were using an in network provider.