Right to a Good Faith Estimate

You have the right to a GOOD FAITH ESTIMATE explaining how much your medical care will cost.

Under the law, health care providers need to give patients who do not have insurance or who choose to not use their existing health insurance to pay for services an estimate of the bill for medical items and services.

You have the right to receive a GOOD FAITH ESTIMATE for the total expected costs of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

This provider only provides non-emergency outpatient services, and does not sell or provide medical tests, prescription drugs, equipment, or hospital services.

Make sure your health care provider provides you with 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 of your choosing, 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 may dispute your bill.

If you elect to seek out of network or cash pay services from this provider, remember to keep a copy of your signed GOOD FAITH ESTIMATE, which your provider will provide, for future reference.

For questions regarding this law, the No Surprises Act, please contact: www.cms.gov/nosurprises.