(415) 555-0142
    No Surprises Act

    Your right to a Good Faith Estimate

    Under federal law, healthcare providers must 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.

    You have the right to:

    • Receive a Good Faith Estimate, in writing, at least 1 business day before your medical service or item, or upon scheduling.
    • Receive a Good Faith Estimate that includes a list of all reasonably expected items and services for the visit—including any related items such as medical tests, prescription drugs, equipment, and hospital fees.
    • Ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.
    • Dispute the bill if it is at least $400 more than the Good Faith Estimate. Disputes must be initiated within 120 calendar days of receiving the bill.

    How to request an estimate

    You may request a Good Faith Estimate at the time of scheduling, when you make an appointment, or any time before your visit.

    By phone

    (415) 555-0142 ext. 3

    Via patient portal

    Submit a Good Faith Estimate request

    At any location

    Ask any front-desk team member

    What's included in an estimate

    Your estimate will include the expected charges for the primary item or service, plus any other items and services that you would reasonably expect to be provided in conjunction with the primary item or service. The estimate is based on information known at the time and may change based on what actually occurs during your visit.

    Disputing a bill

    If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill through the federal Patient-Provider Dispute Resolution process. Start a dispute at cms.gov/nosurprises or by calling 1-800-985-3059.

    Keep your estimate

    Save a copy of your Good Faith Estimate. You may need it if you receive a bill that is significantly higher than the estimate. For questions or more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises.

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