STANDARD NOTICE

“Right to Receive a Good Faith Estimate of Expected Charges”

Under the No Surprises Act

Under section 2799B-6 of the Public Health Service Act, health care providers are required to give individuals who do not have insurance or whoare not planning on using or filing a claim with their plan or coverage an “Good Faith Estimate” of the bill for expected charges.

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/nosurprises or call 615-760-4421.