good faith estimate notice

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

• 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 clients who don’t have insurance or who self-pay for their services an estimate of the bill for medical items and services (including physical therapy).

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services, including physical therapy services.

• Ensure your physical therapist gives you a Good Faith Estimate in writing at least one business day before your services begin. You can also ask your physical therapist 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 or call the U.S. Department of Health and Human Services (HHS) at 1-800-985-3059.