Your Right to Receive a Good Faith Estimate of Expected Charges

• 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 X-rays, lab work such as a crown made by a dental lab, and medications.
• Make sure your provider gives you a Good Faith Estimate in writing at least 1 business day before your service or item. You can also ask your 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 for any provider than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

If you schedule care at least 3 business days ahead, you get the estimate within 1 business day of scheduling. If you schedule at least 10 business days ahead, or ask for an estimate without scheduling, you get it within 3 business days. It comes on paper or electronically, as you prefer.

Tell the front desk when you book that you are paying yourself, or call (704) 555-0129 (demo number). Our published price list is a guide; your Good Faith Estimate is specific to your treatment.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/medical-bill-rights or call the No Surprises Help Desk at 1-800-985-3059.