Good Faith Estimates for Scheduled Services for Uninsured Patients

When we do not have insurance information on file for an upcoming visit, we will provide you with a Good Faith Estimate of the cost of items and services that are reasonably expected for your health care needs and that is based on information known at the time it was created.

If you are billed for more than the Good Faith Estimate amount, you have the right to dispute the bill.

You may contact the health care provider or facility listed to let them know that 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 the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date of 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 the 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.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 1-877-696-6775. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-877-696-6775.

Keep copies of any Good Faith Estimates you receive in a safe place or take pictures of them. You may need them if you are billed a higher amount.