Good Faith Estimate

Good Faith Estimate Information

Beginning January 1, 2022, if you’re uninsured or you pay for health care bills yourself (don’t have your claims submitted to your health plan-Self Pay), health care providers must provide you with an estimate of expected charges before you receive service(s). This is called a “good faith estimate.” Providers/Facilities must provide you with a good faith estimate if you request one, or after you’ve scheduled an item or service. It should include expected charges for the primary item or service you’re getting, and any other items or services that are provided as part of the same scheduled experience.

The provider/facility you contact for a good faith estimate must provide a list of all items and services associated with your care.
Once you receive a good faith estimate from your provider/facility, be sure to keep it in a safe place so you can compare it to any bills you get later. If you’ve had your service and find that the billed amount is at least $400 above the good faith estimate, you may be eligible to file a patient-provider dispute. To locate the form and requirements to file the dispute visit: https://www.cms.gov/files/document/billing-dispute-initiation-form.pdf

Disclaimer A: There may be additional Services recommended that may be requested separately to be performed on the same day or to be scheduled another time.

Disclaimer B: The information provided in this good faith estimate is only an ESTIMATE, actual services and charges may differ from the Good Faith Estimate.

Disclaimer C: Patients may file a PPDR with an independent third party approved by HHS when the Good Faith Estimate is a difference of $400.00 or more. Initiating the PPDR will not adversely affect the quality of healthcare services furnished by the provider or facility. For questions on how to file your PPDR please email: FederalPPDRQuestions@cms.hhs.gov-or call 1-800-985-3059.

Disclaimer D: This is a Good Faith Estimate and not a contract. You are not required to obtain these services because of this estimate.