You have the right to receive a Good Faith Estimate of expected charges under the No Surprises Act.

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

Instructions Under Section 2799B-6 of the Public Health Service Act, health care providers, and healthcare facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.

Good Faith Estimate Form

Disclaimer:

• -The good faith estimate shows you the costs of items and services that are reasonably expected for your health care needs for an item or service. However, this estimate may not include new areas of treatment, new injuries and/or changes in therapy. The estimate is based on the 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 special circumstances occur.