Good Faith Estimate

We would like to let you know about your legal protection from unexpected medical bills. We want to inform you that you may receive services at lower cost from another provider within your insurance network.

You will be provided with a Good Faith Estimate if you are uninsured, decide not to utilize your insurance or the provider/facility is not in your health plan’s network and is considered out-of-network. You may owe the full costs billed for the items and services you get and your health plan might not count any of the amount you pay towards your deductible and out-of-pocket limit. Getting care from this provider or facility will likely cost you more.

UNDERSTANDING YOUR OPTIONS

Before deciding whether to sign the form, you can contact your health plan to find an in-network provider or facility. You can get the items or services described in the Good Faith Estimate notice from a provider or facility in your health plan’s network, which may cost you less. If there is not one, you can also ask your health plan if they can work out an agreement with this provider or facility (or another one) to lower your costs.

DISCLAIMER

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens or if you receive a bill that is at least $400 more than your Good Faith Estimate, federal law allows you to dispute (appeal) the bill. Take a picture and/or keep a copy of the form. It contains important information about your rights and protections.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know 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 to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process with the HHS. If the agency reviewing your dispute agrees with you, you will have to pay the price on this 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 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059.

MORE INFORMATION ABOUT YOUR RIGHTS AND PROTECTIONS

Visit www.cms.gov/nosurprises or call 1-800-985-3059 for more information about the “No Surprises Act” and your rights under federal law.