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*This form is intended for basic information requests and appointment requests only. It is not intended for crisis situations. If you are in a crisis, please call 911 or go to your nearest emergency room*
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.
If your appointment is 3 or more days out we will contact you to provide a Good Faith Estimate. If your appointment is 2 days or less please inquire if you are interested in receiving a Good Faith Estimate.
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.
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate 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.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 407-504-0153.