Good Faith Estimate

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

PDF Copy of Good Faith Estimate

About Good Faith Estimates

If you don’t have insurance or don’t intend to use insurance to pay for scheduled non-emergency health care services, federal law requires that health care providers and facilities provide you with an estimate of the expected charges for medical items and services at least 1 business day before the scheduled services are to be performed

• If you are uninsured or not using insurance to pay for your health care services and receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Any patient may request an estimate of the expected charges for non-emergency health care services that have been ordered, scheduled, or referred, and state law requires that health care providers and facilities provide you with an estimate of the expected bill for medical items and services within 3 business days of the request.

• 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 you request an estimate and the actual charge for the health care services exceeds your Good Faith Estimate by the greater of: (i) $100; or (ii) 5%, we will provide a written explanation as to why the charges exceed the estimate.
• 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, call Scheduling 260-667-5128, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.