Under the No Surprises Act of 2022, 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 certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided. These patients may include: 

• Patients who have insurance but our provider is out-of-network
• Patients whose services are not covered by their insurance
• Patients who opt to not use their insurance
• Self-pay patients

This estimate is intended to provide you with the likely charges you may incur here. You could pay more being seen in this facility than if you were to be seen in-network. You are entitled to seek care in-network and may contact your insurer to see if they contract with any competent providers within the area. You aren’t required to sign this form.

It is your responsibility to contact your insurer to verify that we are in-network with your plan. If you are insured with one of our contracted plans, the below will only apply IF you ever find yourself without that insurance or you opt not to use your insurance. Disclaimer: This Good Faith Estimate shows the costs of items and services that are reasonably expected based on your health care needs. The estimate is based on information known at the time the estimate was created. It 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, federal law allows you to dispute (appeal) the bill.

This Good Faith Estimate is not a contract and does not require you to obtain the services from the providers or facility identified in it. You have the right to request another Good Faith Estimate at any time during your course of care. 

• 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 within 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 any 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 the actual billed service charges exceed this estimate by $400 or more, then you (the patient) have the right to dispute the bill via the patient-provider dispute resolution process with the U.S. Department of Health and Human Services (HHS). Please feel free to contact us first so that we may address any glaring discrepancy. 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. 

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email [email protected], or call 1-800-985-3059