Good Faith Estimate Rights Notice
Under federal law, health care providers and facilities must give patients who do not have insurance or who are not using insurance an estimate of expected charges for scheduled or requested health care items and services.
Who May Receive a Good Faith Estimate
You generally qualify as uninsured or self-pay when you do not have health insurance benefits for an item or service, or you choose not to submit a claim to your health plan for that item or service.
When You Should Receive the Estimate
- If you schedule an item or service at least 3 business days before it will be provided, the estimate generally must be given in writing no later than 1 business day after scheduling.
- If you schedule an item or service at least 10 business days before it will be provided, the estimate generally must be given in writing no later than 3 business days after scheduling.
- If you ask for an estimate before scheduling, the estimate generally must be given in writing no later than 3 business days after the request.
The estimate should include expected charges for the primary item or service and other items or services reasonably expected to be provided as part of the scheduled care. It is an estimate, not a bill, and actual charges may differ when the course of care changes or unanticipated services become necessary.
Requesting an Estimate
| Contact | [GFE CONTACT TITLE] |
|---|---|
| Telephone | [GFE PHONE] |
| [GFE EMAIL] | |
| Scheduling | Request or schedule services |
| Mailing Address | [MAILING ADDRESS] |
If Your Bill Is Higher Than the Estimate
Keep a copy of your Good Faith Estimate. If billed charges from a provider or facility are at least $400 more than the expected charges listed for that provider or facility, you may be eligible to use the federal patient-provider dispute resolution process. A request generally must be filed within 120 calendar days of the date on the initial bill.
For questions about federal medical-bill rights, call 1-800-985-3059.