Good Faith Estimate

Under the No Surprises Act (H.R. 133 - effective January 1, 2022), health care providers need to give clients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

• You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services.  This includes related cost like medical tests, prescription drugs, equipment, and hospital fees.  ​
  

• Make sure you receive a Good Faith Estimate for items and services within the following timeframes from your health care provider or facility:
  

  • ​​If you schedule at least 3 business days in advance, you should receive a Good Faith Estimate in writing within 1 business day after scheduling.
    

  • If you schedule at least 10 business days in advance, you should receive a Good Faith Estimate in writing within 3 business days after scheduling.
    

  • If you request a Good Faith Estimate before you schedule, you should receive the estimate in writing within 3 business days after you ask.

• The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. 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 that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.
  

  • You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance 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 4 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 Good Faith Estimate. 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 to save a copy or take a picture of your Good Faith Estimate and the bill. ​

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

OMB Control Number 0938-1433 - Expiration Date 11/2025

This is the public disclosure of the "Good Faith Estimate."​

A Good Faith Estimate is for your awareness only. It does NOT involve you needing to make any type of commitment.