NOTICE: Good Faith Estimate

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

• Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an 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, prescription drugs, equipment, and hospital fees.

• Make sure your healthcare provider gives you 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 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. I understand if I have questions or for more information about my right to a Good Faith Estimate or the dispute process, I may visit www.cms.gov/nosurprises or 1(800)368-1019

• Make sure to save a copy or picture of your Good Faith Estimate