Good Faith Estimate

[Note: Providers may use this sample Good Faith Estimate Notice to comply with the No Surprises Act. The Act requires providers to inform their uninsured and private pay patients that they have a right to a “Good Faith Estimate” to help them estimate the expected charges they may be billed. Information regarding the availability of a “Good Faith Estimate” must be prominently displayed on the provider’s and website and in the office and on-site where scheduling or questions about the cost of health care occur.]

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.

Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a 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.