Good Faith Estimate Disclaimer
You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost.
Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for healthcare items and services before those items or services are provided.
• You have the right to receive a Good Faith Estimate for the total expected cost of any health care
items or services upon request or when scheduling such items or services. This includes related costs
like medical tests, prescription drugs, equipment, and hospital fees.
• If you schedule a health care item or service at least 3 business days in advance, make sure your
health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after
scheduling. If you schedule a health care item or service at least 10 business days in advance, make
sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business
days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate
before you schedule an item or service. If you do, make sure the health care provider or facility gives
you a Good Faith Estimate in writing within 3 business days after you ask.
• If you receive a bill that is at least $400 more for any provider or facility than your Good Faith
Estimate from that provider or facility, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate and the bill.
For questions or more information about your right to a Good Faith Estimate, visit
www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-
PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this form and any
supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section
112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L.
116-260). We need the information on the form to process your request to initiate a payment dispute,
verify the eligibility of your dispute for the PPDR process, and to determine whether any conflict of
interest exists with the independent dispute resolution entity selected to decide your dispute. The
information may also be used to: (1) support a decision on your dispute; (2) support the ongoing
operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with
program rules. Providing the requested information is voluntary. But failing to provide it may delay or
prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider