STANDARD NOTICE
“Right to Receive a Good Faith Estimate of Expected Charges”
Under the No Surprises Act

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 one business day before your medical service or item. 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 service.

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 The Joshua Center at (479) 373-2377