Health care providers are required to provide a Good Faith Estimate of expected charges to individuals who are not enrolled in an insurance plan or coverage or a federal health care program, or not seeking to file a claim with their plan or coverage. 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 therapy sessions, diagnostic tests, and other services.

• If you are uninsured or choose not to use insurance, I will provide you with a written Good Faith Estimate before we schedule a service, or upon your request.

• 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 or call (800) 368-1019.