Notice of Your Right to a
Good Faith Estimate

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 clients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of your healthcare services, including psychotherapy services. 

 

You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. The Good Faith Estimate shows the costs of items and services that are reasonably expected for your healthcare needs for an item or service. The estimate is based on information known at the time the estimate is created. 

 

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during the course of care. You could be charged more if special circumstances occur. In non-emergency circumstances, you will be provided with an updated Good Faith Estimate for any new expected charges.

 

If you are billed for more than your Good Faith Estimate, you have the right to dispute the bill under federal law. Specifically, if you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. 

 

You may contact the healthcare provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. 

 

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute within 120 calendar days (about 4 months) of the date of the original bill.

 

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on the Good Faith Estimate. If the agency disagrees with you and agrees with the healthcare provider or facility, you will have to pay the higher amount.

 

To learn more or to get a form to start the dispute resolution process, go to www.cms.gov/nosuprises or call HHS’ toll free number: 1-877-696-6775.

 

Make sure to keep a copy of your Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

 

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call HHS’ toll free number: 1-877-696-6775.