NO SURPRISE ACT NOTICE

YOUR RIGHT TO A “GOOD FAITH ESTIMATE”

You have the right to receive a ‘Good Faith Estimate’ explaining how much your medical care may cost.

Under the law, health care providers need to give patients who do not have insurance, or who are not using insurance, a cost 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, drugs, equipment, and hospital fees.

Your health care provider must give you a ‘Good Faith Estimate’ in writing for scheduled services within designated timeframes. You can also ask your health care provider 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-MEDICARE (1-800-633-4227).