Under the No Surprises Act (H.R. 133 - effective January 1, 2022), health care providers need to give clients or patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.

• This Good Faith Estimate (GFE) shows the costs of items and services you can reasonably expect for your health care needs. 
• This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. The estimate is based on information known at the time the estimate was created. 
• You have the right to receive a GFE for the total expected cost of any non-emergency items or services. 
• The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. There may be additional items or services that may be recommend as part of your care that must be scheduled or requested separately and are not reflected in this Good Faith Estimate. 
• You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
• If you receive a bill at least $400 more than your GFE, you may dispute or appeal the bill.
  • You may contact the health care provider or facility listed to let them know the billed charges are higher than the GFE. You may ask them to update the bill to match the GFE, negotiate the bill, or ask if financial assistance is available. 
  • You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about four months) of the date on the original bill. 
  • There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. 
• Make sure your health care provider gives you a GFE within the following timeframes:
  • If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling;
  • If the service is scheduled at least ten business days before the appointment date, no later than three business days after the date of schedule; or
  • If the uninsured or self-pay client requests a GFE (without scheduling the service), no later than three business days after the date of the request. Healthcare providers must supply a new GFE within the specified timeframes if the patient reschedules the requested item or service.

Note: A Good Faith Estimate is for your awareness only and does not require immediate financial commitment or payment. 

To learn more, go to www.cms.gov/nosurprises or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you receive a bill in a higher amount.

If you have questions or concerns, please reach out.