Chiropractor in Lansing, MI
Privacy Policy
OMB Control Number: 1210-0169
Appendix 1
Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act
(For use by health care providers, facilities, and providers of air ambulance services no later than January 1, 2022)
Instructions:
Under Section 2799B-6 of the Public Health Service Act and its implementing regulations, health care providers and facilities are required to inform individuals who are not enrolled in a group health plan, group or individual health insurance coverage, a Federal health care program, or a Federal Employees Health Benefits (FEHB) program (uninsured individuals), or who are not seeking to file a claim with their group health plan, health insurance coverage, or FEHB plan (self-pay individuals), in writing (and orally if requested), of their right to receive a “Good Faith Estimate” of expected charges.
This form may be used by health care providers and facilities to inform uninsured (or self-pay) individuals of their right to a “Good Faith Estimate” to help them estimate expected charges for health care items and services. Information about the availability of a “Good Faith Estimate” must be prominently displayed on the provider’s and facility’s website, in the office, and on-site where scheduling or cost inquiries occur.
To use this model notice, providers or facilities must complete the blanks with appropriate information. HHS considers the use of this model notice as good faith compliance with the requirement to inform individuals of their right to a Good Faith Estimate. Use of this model notice is not mandatory but is provided to facilitate compliance.
Note: The information in these instructions is intended to be a general informal summary of legal standards. It is not a substitute for the statutes, regulations, or formal policy guidance on which it is based. Readers should refer to the applicable statutes, regulations, and other materials for complete and current information, including the HHS interim final rules (IFR) titled Requirements Related to Surprise Billing; Part II, published on October 7, 2021.
For ease of reference, the term “provider” includes providers of air ambulance services.
Health care providers and facilities should not include these instructions with documents given to patients.
Paperwork Reduction Act Statement:
According to the Paperwork Reduction Act of 1995, no one is required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 1210-0169. The estimated time required to complete this collection is 1.3 hours per response, including reviewing instructions, searching data resources, gathering necessary data, and completing the collection. For comments concerning the accuracy of time estimates or suggestions for improvement, write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
You Have the Right to Receive a “Good Faith Estimate” Explaining the Cost of Your Health Care:
Under the law, health care providers must provide patients who don’t have certain types of health coverage, or who are not using health coverage, with an estimate of the bill for health care items and services before those items or services are provided.
• You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling them. This includes costs such as medical tests, prescription drugs, equipment, and hospital fees.
• If you schedule a health care item or service at least 3 business days in advance, your health care provider or facility must give you a Good Faith Estimate in writing within 1 business day of scheduling. If you schedule a health care item or service at least 10 business days in advance, your health care provider or facility must provide a Good Faith Estimate in writing within 3 business days of scheduling. You may also request a Good Faith Estimate before scheduling an item or service. If requested, the provider or facility must provide the estimate in writing within 3 business days.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Be sure to save a copy or picture of your Good Faith Estimate and the bill.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.
Privacy Act Statement:
CMS is authorized to collect information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, Title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). The information on this form is required to process your request to initiate a payment dispute, verify eligibility for the PPDR process, and determine whether there is a conflict of interest with the independent dispute resolution entity deciding your dispute. The information may also be used to support a decision on your dispute, support the ongoing operation and oversight of the PPDR program, and evaluate selected IDR entity compliance. Providing this information is voluntary, but failure to provide it may delay or prevent processing of your dispute or could cause it to be decided in favor of the provider or facility.