Original January 1, 2022

Appendix 1 

Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act 

Instructions 

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities  are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care  program, or not seeking to file a claim with their plan or coverage both orally and in writing of their  ability, upon request or at the time of scheduling health care items and services, to receive a “Good  Faith Estimate” of expected charges.  

This form may be used by the health care providers to inform individuals who are not enrolled in a plan  or coverage or a Federal health care program (uninsured individuals), or individuals who are enrolled  but not seeking to file a claim with their plan or coverage (self-pay individuals) of their right to a “Good  Faith Estimate” to help them estimate the expected charges they may be billed for receiving certain  health care items and services. Information regarding the availability of a “Good Faith Estimate”  must be prominently displayed on the convening provider’s and convening facility’s website and in  the office and on-site where scheduling or questions about the cost of health care occur. 

To use this model notice, the provider or facility must fill in the blanks with the appropriate information.  HHS considers use of the model notice to be good faith compliance with the good faith estimate requirements to inform an individual of their rights to receive such a notice. Use of this model notice is not required and is provided as a means of facilitating compliance with the applicable notice  requirements. However, some form of notice, including the provision of certain required information, is  necessary to begin the patient-provider dispute resolution process. 

NOTE: The information provided in these instructions is intended only to be a general informal  summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or  formal policy guidance upon which it is based. Readers should refer to the applicable statutes,  regulations, and other interpretive materials for complete and current information. [Link to IFR when  available.]  

Health care providers and facilities should not include these instructions with the documents given  to patients.  

Paperwork Reduction Act Statement 

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of  information unless it displays a valid Office of Management and Budget (OMB) control number. The  valid OMB control number for this information collection is 0938-XXXX. The time required to  complete this information collection is estimated to average 1.3 hours per response, including the time to  review instructions, search existing data resources, gather the data needed, and complete and review the  information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports  Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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 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.

For questions or more information about your right to a Good Faith Estimate, visit  www.cms.gov/nosurprises  

QUESTIONS OR SUGGESTIONS

If you have questions or concerns about the Good Faith Estimate, please contact us:

By Repose LCSW PLLC and By Repose LLC
46 Guion St., Pleasantville, NY 10570

hello@byrepose.com
+1 212 920 1976