Good
Faith Estimate

The Federal No Surprise Act

Good Faith Estimate 

PATIENTS WHO DON’T HAVE INSURANCE OR CHOOSE NOT TO USE THEIR INSURANCE HAVE A RIGHT TO RECEIVE A “GOOD FAITH ESTIMATE” OF HOW MUCH THEIR MEDICAL CARE WILL COST. 

If you do NOT have insurance or choose not to use your insurance, you have a right to request and receive a Good Faith Estimate of how much your non-emergency health care items and services will cost.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency medical items or services. This includes related costs like medical tests, prescription drugs, medical equipment and hospital fees. 

  • Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item is scheduled to be provided. If you schedule a medical service or item to be provided within three days of making the appointment, your health care provider will use reasonable efforts to provide you with a Good Faith Estimate before you are provided with the service or item. 

  • If you receive a bill that is more than $400 more than the Good Faith Estimate provided to you, you can dispute the bill.

  • Be sure to save a copy or take a photo of the Good Faith Estimate that was provided to you. For more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059. 

DISCLAIMER 

This Good Faith Estimate shows the estimated costs of items and services that are reasonably expected for your health care needs. The estimate is based upon information known at the time the estimate was calculated and is NOT the final overall total charge for the items and services. 

The Good Faith Estimate does NOT include any unknown or unexpected costs that may arise as part of the course of care that must be scheduled separately, such as rehabilitation therapy or other post-treatment items or services.

If and when such additional items and services are scheduled, you may request a separate Good Faith Estimate for those items and services.

The Good Faith Estimate provided to you is NOT a contract and does NOT require you to obtain the items and services from any of the providers or facilities identified on the Good Faith Estimate.

Dispute Resolution


If your final bill is more than $400 more than the Good Faith Estimate provided to you for any provider or facility, you have the right to dispute the bill. 

If you choose to dispute your bill, you must contact the health care provider or facility to let them know the billed charges are higher than the Good Faith Estimate. You may ask them to update the bill to match the Good Faith Estimate, negotiate the amount or ask if financial assistance is available to help you pay the bill. 

If you are not satisfied, you may begin a dispute resolution process through the U.S. Department of Human Services. 

If you choose to use the dispute resolution process, you must start that process within 120 calendar days (about four months) from the date on the original bill. 

If you start a dispute resolution process, the provider or facility may not send your disputed bill to collection or threaten to do so. If the bill has already been sent for collection before you elect to dispute it, the provider or facility must stop all collection activities and suspend all late fees until the dispute is resolved. The provider or facility may not retaliate against you for disputing your bill.

There is a $25 fee to use the dispute resolution process. If you win the dispute, you will have to pay the amount on the Good Faith Estimate, reduced by the $25 fee. If the Selected Dispute Resolution entity does not agree with you and you lose the dispute, you will have to pay the bill, and your $25 fee will not be reimbursed to you. 

To learn more about the dispute resolution process or get a form to start a dispute, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059. 

If you have questions or need more information about your right to a Good Faith Estimate or dispute process, visit www.cms.nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov or call 1-800-985-3059. 

BE SURE TO KEEP A COPY OF YOUR GOOD FAITH ESTIMATE IN A SAFE PLACE. YOU MAY NEED IT IF YOU ARE BILLED A HIGHER AMOUNT.

We are committed to ensuring that our patients receive appropriate medical care. You can get information regarding your rights and how to report professional misconduct at https://www.health.ny.gov/professionals/doctors/conduct