By 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.

A “Good Faith Estimate” shows the costs of items and services that are reasonably expected for your health care needs for a non-emergency item or service, including related costs such as prescription drugs, hospital fees, medical tests, and equipment. The estimate is based on information known at the time the estimate was created and does not include any unknown or unexpected costs that may arise during treatment.

Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional service costs are in addition to the Good Faith Estimate.

If your needs change during treatment, your provider should supply a new, updated Good Faith Estimate to reflect the changes to treatment, and the accompanying cost changes.

**If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.**

You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 985-3059.

If you believe you’ve been wrongly billed, you may contact:

The Office of the Secretary of State
1700 W Washington St Fl 7
Phoenix AZ 85007-2808

1 (602)-542-4285

The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

**Keep a copy of your “Good Faith Estimate” in a safe place or take pictures of it. You may need it if you are billed a higher amount.**

Good Faith Estimate