Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your
medical care will cost

Under state and federal law, a patient may ask a health care provider for a Good Faith Estimate
of the price the health care provider and health facility will charge for providing a nonemergency
health care service, including costs such as medical tests, prescription drugs, equipment, and
hospital fees. The Good Faith Estimate will be made in writing and provided within the
timeframes stated in this notice.

• Any Patient. Any patient (insured, uninsured, or self-pay) may request a Good Faith
  Estimate of expected charges for nonemergency health care services. When one is
  requested, you will be provided a copy of this Good Faith Estimate within 3 business
  days of the request (when uninsured or self-pay) and 5 business days (when insured).
• Uninsured Patients. Federal law requires health care providers to give you a Good
  Faith Estimate in advance of scheduling or upon request if you are uninsured or self-pay
  (not using your insurance to pay for the item or service). The Good Faith Estimate will be
  provided within 3 business days of scheduling the nonemergency health care service or
  within 1 business day if the nonemergency health care service is scheduled to be
  performed by the practitioner within 3 business days.

You may ask your health care provider, and any other provider you choose, for a Good Faith
Estimate before you schedule an item or service.

Patients who are uninsured or self-pay may dispute the actual charges if the exceed the Good
Faith Estimate by at least $400.00.

Make sure to save a copy of your Good Faith Estimate.

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