Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act

OMB Control Number 0938-XXXX 

Expiration Date: No expiration date.

This is to inform individuals who are not enrolled in a plan or coverage or a Federal health care program (uninsured individuals), or individuals who are enrolled but not seeking to file a claim with their plan or coverage (self-pay individuals) of their right to a “Good Faith Estimate” to help them estimate the expected charges they may be billed for receiving  health care services (including outpatient telepsychology services) and other services. Information regarding the availability of a “Good Faith Estimate” bill.

• •You have the right to receive a “Good Faith Estimate” explaining how much your medical 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 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. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• 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.
  For questions or more information about your right to a Good Faith Estimate, visit
  www.cms.gov/nosurprises