No Surprises Act Notice

Your Right to a “Good Faith Estimate”

Under the law, health care providers need to give patients who don’t have insurance (self-pay) or who are not using insurance an estimate of the anticipated charges 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 upon request or when scheduling.
• Your health care provider must provide you with a Good Faith Estimate in writing at least 1 business day before your scheduled 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 Estimate.

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