Under Section 2799B-6 of the PublicHealth Service Act, health care providers and health care facilities arerequired to inform individuals who are not enrolled in a plan or coverage or aFederal health care program, or not seeking to file a claim with their plan orcoverage both orally and in writing of their ability, upon request or at thetime of scheduling health care items and services, to receive a “Good FaithEstimate” of expected charges.
This form may be used by the health care providers to informindividuals who are not enrolled in a plan or coverage or a Federal health careprogram (uninsured individuals), or individuals who are enrolled but notseeking to file a claim with their plan or coverage (self-pay individuals) oftheir right to a “Good Faith Estimate” to help them estimate the expectedcharges they may be billed for receiving certain health care items andservices. Information regarding the availability of a “Good Faith Estimate” mustbe prominently displayed on the convening provider’s and convening facility’swebsite and in the office and on-site where scheduling or questions about thecost of health care occur.
To use this model notice, the provider or facility must fillin the blanks with the appropriate information. HHS considers use of the modelnotice to be good faith compliance with the good faith estimate requirements toinform an individual of their rights to receive such a notice. Use of thismodel notice is not required and is provided as a means of facilitatingcompliance with the applicable notice requirements. However, some form ofnotice, including the provision of certain required information, is necessaryto begin the patient-provider dispute resolution process.
NOTE: The information provided in these instructions isintended only to be a general informal
summary of technical legal standards. It is not intended totake the place of the statutes, regulations, or formal policy guidance uponwhich it is based. Readers should refer to the applicable statutes, regulations,and other interpretive materials for complete and current information.
Health care providers and facilities should not include these instructions with the documents given to patients.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no personsare required to respond to a collection of information unless it displays avalid Office of Management and Budget (OMB) control number. The valid OMBcontrol number for this information collection is 0938-XXXX. The time requiredto complete this information collection is estimated to average 1.3 hours perresponse, including the time to review instructions, search existing dataresources, gather the data needed, and complete and review the informationcollection. If you have comments concerning the accuracy of the timeestimate(s) or suggestions for improving this form, please write to: CMS, 7500Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,Baltimore, Maryland 21244-1850.
Under the law, health care providers need to give patientswho don’t have insurance or who are not using insurance an estimate of the billfor medical items and services.
You have the right to receive a Good Faith Estimate for thetotal expected cost of any non-emergency items or services. This includes relatedcosts like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good FaithEstimate in writing at least 1 business day before your medical service oritem. You can also ask your health care provider, and any other provider you choose,for a Good Faith Estimate before you schedule an item or
If you receive a bill that is at least $400 more than yourGood Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good FaithEstimate.
For questions or more information about your right to a GoodFaith Estimate, visit www.cms.gov/nosurprises or email email@example.com.