Good Faith Estimate & Disclosure

You have the right to receive a “Good Faith Estimate” explaining how much your health 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 health care items and services before those services are provided.

• You have the right to receive a Good Faith Estimate for the total expected cost of any nonemergency health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing at least 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask your health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.

• 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 and the bill.

For questions or more information about your right to a Good Faith Estimate, www.cms.gov/nosurprises or email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

Disclaimers: There may be additional items or services that we recommend as part of the course of care that
must be scheduled or requested separately and are not reflected in this Good Faith Estimate. The information
provided in this Good Faith Estimate is only an estimate of items or services reasonably expected to be furnished at
the time this Good Faith Estimate was and actual items, services, or charges may differ from the good faith estimate.

You have the right to initiate the patient-provider dispute resolution process if the actual billed charges are $400
more than the expected charges included in the Good Faith Estimate and the dispute is initiated within 120 days after
the date of the bill for the items or services. To start the process, you may contact us at the phone number or address
listed above to let us know the billed charges are higher than the Good Faith Estimate. You can ask us 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 within 120
calendar days (about 4 months) of the date on the original bill and if the agency disagrees with you, 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. This
Good Faith Estimate is not a contract and does not require you to obtain the items or services from any of the
providers or facilities identified in the Good Faith Estimate.