STANDARD NOTICE:

“RIGHT TO RECEIVE A GOOD FAITH ESTIMATE OF EXPECTED CHARGES” UNDER THE “NO SURPRISES ACT”

Effective 01/01/2022

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” explaining how much your medical and health care will cost. 
• Health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including speech therapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.
• 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 (720) 845-6600.