[[ Good Faith Estimate Notice  ]]

Effective date: [[ 1/112022]]

In accordance with Title I (No Surprises Act) of Division BB of the Consolidated Appropriations Act, 2021 (CAA) amended title XXVII of the Public Health Service Act (PHS Act), Part E:

You, as a consumer, have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under an amended addition to the act (Part E), health care providers are required to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

Your health care provider is to provide a written Good Faith Estimate at least 1 business day prior to your medical service or item. You may also request a Good Faith Estimate be sent to you prior to scheduling and item or service. (PHSA 2799B-6; 45 CFR 149.610)

If you receive a bill that is at least $400 more than your Good Faith Estimate, you may start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). It is advised 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 the Department of Health & Human Services (HHS) at 1-877-696-6775.