Personalized Care For Peak Performance

• 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 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.

Disclaimers:
- The patient may be recommend additional services or items as part of the course of care that must be scheduled or requested separately and are not reflected in this good faith estimate.
- The information is only an estimate of what is reasonably expected to be furnished at the time the good faith estimate is issued, and that actual services, items, or charges may differ.
- The patient has the right to initiate a patient-provider dispute if the actual billed charges are substantially higher than the expected charges included in the good faith estimate. Please contact our office to find information about initiating the dispute resolution process and state that initiation of the process will not adversely affect the quality of the health care services received.
- The good faith estimate is not a contract and does not require the patient to obtain the services or items from any of the providers or facilities identified in it.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call our office at (512) 522-3214.