OMB Control Number: 0938-1401
Expiration Date: 03/31/2022
The contents of this document do not have the force and effect of law and are not meant to bind the public in anyway, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.
Model Disclosure Notice Regarding Patient Protections Against Surprise Billing
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.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item.
You can also ask your health care provider, 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 1-800-985-3059.
