Good Faith Estimate

You have the right to receive a "Good Faith Estimate" explaining how much your health care will cost. Under the law, healthcare providers need to give patients who don't have certain types of health care coverage or who are not using certain types of healthcare 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 healthcare items or services upon request or when scheduling those items or services. 
  • *If you have scheduled health care items or services at least three 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 health care items or services at least ten days before your appointment, make sure your health care provider or facility gives you a Good Faith Estimate within three days of scheduling. 
  • *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 your bill. Make sure to have a copy of the original Good Faith Estimate and the bill.
  • For more information about your right to a Good Faith Estimate, visit www.cms/nosurprises/consumers, email:FederalPPDRQuestions@cms.hhs.gov, or call 1 (800) 985-3059.

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 or facility.