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, hospital fees, and mental health services.
• Make sure your health care/Mental health provider gives you a Good Faith Estimate in writing at least 3 business days before your medical or counseling services. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an appointment.
• 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.
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For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or Restoring Lives Family Services Center LLC at 305-814-3437