Good Faith Estimate

STANDARD NOTICE

“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 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 one 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 contact Ariadne Crane at Balance, Harmony &

Restoration

Counseling LLC via email acrane@bhrcounseling.org or call at 404-988-9591.