Good Faith Estimates and the “No Surprises” Act (H.R. 133)

Effective January 1, 2022

 

You are entitled to receive a “Good Faith Estimate” of what the charges could be for health services provided to you. While it is not possible for the provider to know in advance how many visits may be necessary or appropriate for a given client, this form provides an estimate of the cost of services provided. The total cost of services will depend upon the number of visits attended, the client’s individual circumstances, and the type and amount of services that provided.

 

There may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in this good faith estimate. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here.

 

You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).

 

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call 1-800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.