Right to a Good Faith Estimate

Under the law, if you are paying for services out-of-pocket, whether you do not have insurance or opt not to use insurance, you have the right to request and receive a “Good Faith Estimate” explaining in writing how much your medical care will cost. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

If you schedule a health care item or service at least three business days in advance, you must be provided a Good Faith Estimate in writing one business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, you must be provided a Good Faith Estimate in writing within three business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, you must be provided a Good Faith Estimate in writing within three business days after you ask.

PLEASE ADVISE US IF YOU WILL BE PAYING OUT-OF-POCKET AND, IF SO, WHETHER YOU WOULD LIKE A GOOD FAITH ESTIMATE FOR THE COST OF ANTICIPATED SERVICES.

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