NO SURPRISE ACT NOTICE
YOUR RIGHT TO A “GOOD FAITH ESTIMATE”
You have the right to receive a ‘Good Faith Estimate’ explaining how much your medical care may cost.
• Under the law, health care providers need to give patients who do not have insurance, or who are not using insurance, a cost 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, drugs, equipment, and hospital fees.
• Your health care provider must give you a ‘Good Faith Estimate’ in writing for scheduled services within designated timeframes. You can also ask your health care provider 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 questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.