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Good Faith Estimate

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 do not 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 you 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 you Good Faith Estimate, you can dispute this 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

Request a Good Faith Estimate

Please complete this form to request a Good Faith Estimate if you are using out of network benefits or do not have insurance coverage

Please, choose your contact preference:

*By sending my request, I am waiving my right to receive this estimate via secure means. I understand that the follow up e-mail is not HIPAA compliant and may include protected health information. If I do not authorize this I understand that I can call the office at (609)798-1876 and request an estimate via US mail.