Good Faith Estimate Notice
Under the law, health care providers need to give patients who don’t haveinsurance or who are not using insurance an estimate of the bill for medicalitems and services.
- You have the right to receive a Good Faith Estimate for the totalexpected cost of any non-emergency items or services. This includesrelated costs like medical tests, prescription drugs, equipment, andhospital fees.
- Make sure your health care provider gives you a Good Faith Estimatein writing at least 1 business day before your medical service or item.You can also ask your health care provider, and any other provider youchoose, for a Good Faith Estimate before you schedule an item orservice.
- If you receive a bill that is at least $400 more than your Good FaithEstimate, 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 or the dispute process, visit
www.cms.gov/nosurprises or call 800- 985-3059.
You may also have rights under the New York Emergency Medical Services and Surprise Bill Act. For more information call 800-342-3736 or email firstname.lastname@example.org. You may also file a complaint at