Under the law, health care providers need to give patients who don’t have health care coverage or who are not using health care coverage an estimate of their bill for health care items and services, before those items and services are provided.
You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request, or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
If you schedule a health care item or service at least 3 business days in advance, your health care provider or facility should provide you with a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, your health care provider or facility should provide you with a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, the health care provider or facility should provide you with a Good Faith Estimate in writing within 3 business days after you ask.
If you receive a bill from your health care provider or facility that is at least $400 more than your Good Faith Estimate from that provider or facility, you can dispute this bill.
Should your needs change during the course of treatment, your healthcare provider or facility should provide you with a new, updated Good Faith Estimate to reflect the changes in cost.
For more information about your right to a Good Faith Estimate, please:
• Visit: www.cms.gov/nosurprises/consumers
• Email: FederalPPDRQuestions@cms.hhs.gov
• Call: 1-800-985-3059
PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to: (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.