Your Right to a Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Understanding Your Rights
Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.
What Is Included in Your Good Faith Estimate?
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.
When Should You Receive Your Estimate?
- Scheduling at least 3 business days in advance:
Your health care provider or facility must give you a Good Faith Estimate in writing within 1 business day after scheduling. - Scheduling at least 10 business days in advance:
Your health care provider or facility must give you a Good Faith Estimate in writing within 3 business days after scheduling. - Requesting an estimate before scheduling:
You can ask any health care provider or facility for a Good Faith Estimate before scheduling an item or service. The provider or facility must give you the estimate in writing within 3 business days after your request.
What If Your Bill Is Higher Than Your Estimate?
If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.
Important:
Make sure to save a copy or picture of your Good Faith Estimate.
Questions or More Information?
For questions or more information about your right to a Good Faith Estimate, visit:
Website:
www.cms.gov/nosurprises/consumers
Email:
FederalPPDRQuestions@cms.hhs.gov
Phone:
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:
- Support a decision on your dispute.
- Support the ongoing operation and oversight of the PPDR program.
- 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.