Your Right to a Good Faith Estimate

DRAFT — not yet published. The content below follows the federal model language and must be reviewed and completed by the practice before it goes live. Every [CONFIRM: …] marker is a fact only the practice can supply.

Under the federal No Surprises Act, you have the right to receive a Good Faith Estimate explaining how much your medical care will cost.

Who this is for

If you do not have health insurance, or if you have insurance but choose not to use it for a visit, you have the right to receive a Good Faith Estimate of the expected charges for the services you are scheduling.

What you are entitled to

• A Good Faith Estimate in writing at least one business day before your medical service, if you schedule it at least three business days in advance.
• A Good Faith Estimate on request, before you schedule anything. Ask us and we will provide one.
• The estimate covers the reasonably expected charges for the items and services being scheduled, including related items and services we expect to provide.

If your bill is much higher than your estimate

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill through the federal patient-provider dispute resolution process. You must start the dispute within 120 calendar days of the date on the bill.

Keep a copy or picture of your Good Faith Estimate.

How to ask for one

• Phone: (630) 324-6825
• Email: info@immediatecarewestmont.com
• In person at either clinic.

For more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises or call 1-800-985-3059.

[CONFIRM: the practice must also post this notice prominently in the office and on-site where scheduling happens, not only on the website.]