Disclaimer:
This Good Faith Estimate shows the costs of items and services that are reasonably
expected for your health care needs for an item or service. The estimate is based on
information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that
may arise during treatment. You could be charged more if complications or special
circumstances occur. If this happens, federal law allows you to dispute (appeal) the
bill.
If you are billed for more than this Good Faith Estimate, you have the right to
dispute the bill.
You may contact the health care 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 process within 120 calendar days (about 4 months) of
the date on 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 this Good Faith Estimate. If the
agency disagrees with you and agrees with the health care provider or facility, you
will have to pay the higher amount.
To learn more and get a form to start the process, go to
https://www.cms.gov/nosurprises/consumers or call 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or
the dispute process, visit
https://www.ems.gov/nosurprises/consumers or call 1-800-985-3059.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You
may need it if you are billed a higher amount.
