Good Faith Estimate Notice

• You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, healthcare providers need to give patients who don’t have certain types of healthcare coverage or who are not using certain types of healthcare coverage an estimate of the expected charges for medical services, including psychotherapy services before those items or services are provided.
• You have the right to receive a Good Faith Estimate for the total expected total cost of any non-emergency healthcare services, including psychotherapy services. You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate any time or when scheduling appointments or services. The Good Faith Estimate includes related costs like medical tests, prescription drugs, equipment, and hospital or clinic fees.
• If you schedule an appointment or service at least 3 business days in advance, make sure your healthcare provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule an appointment or service at least 10 business days in advance, make sure your healthcare provider or facility gives you a Good Faith Estimate in writing within 3 business days after  scheduling. You can also ask any healthcare provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure your healthcare provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
• 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 call 1-800-985-3059.