OMB Control Number [0938-XXXX]
Expiration Date 01/01/2025
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 for the total
expected cost of any non-emergency items or services. This
includes related costs like medical tests, prescription drugs,
equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in
writing at least 1 business day before your medical service or item.
You can also ask your healthcare 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 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 1-877-696-6775.