Good Faith Estimate
Your right to a Good Faith Estimate.
You have the right to receive a Good Faith Estimate explaining how much your medical care will cost.
Template for review: confirm wording and dispute details against current CMS guidance before publishing.
Your right
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.
- Make sure your provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask for one before you schedule.
Our expected charges
| Service | Length | Charge |
|---|---|---|
| Initial psychiatric evaluation | 60 min | $395 |
| Follow-up visit | 30 min | $185 |
| Extended follow-up visit | 45 min | $275 |
Your personal estimate will list the visits expected over a set period of care. Lab tests and medications are billed separately by the lab and pharmacy and are not included.
If your bill is higher
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.
Learn more
For questions or more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.