Good Faith Esti­mate of Expect­ed Charges

Stan­dard Notice
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Right to Receive a Good Faith Esti­mate of Expect­ed Charges Under the No Sur­pris­es Act

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

Under the law, health care 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 health care provider gives you a Good Faith Esti­mate in writ­ing at least one 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.

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/​n​o​s​u​r​p​rises or call Cus­tomer Account Ser­vices (847) 5248800197

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