Good Faith Estimate for Health Care Items and Services:

The Federal No Surprises Act, effective January 1, 2022, requires healthcare providers to inform clients of their rights and protections against “surprise billing.” This includes notifying you of your rights when services are provided by an out-of-network provider if you are uninsured or choose not to use your insurance. Additionally, a Good Faith Estimate of service costs will be provided at no charge to you.

This Good Faith Estimate outlines the expected costs for your treatment based on current information. It does not account for unknown or unexpected costs that may arise during the treatment process. Should complications or special circumstances occur, you may be charged more. If this happens, you have the right to dispute the bill.

If your bill exceeds the Good Faith Estimate, you can contact the healthcare provider to discuss the charges or initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS) within 120 calendar days of the original bill date. There is a $25 fee to use this process. If the reviewing agency agrees with you, you will pay the estimated amount. If not, you will pay the higher amount.

For more information or to start the dispute process, visit www.cms.gov/nosurprises or call me at 913-353-5450. For questions about your rights or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019. Keep a copy of your Good Faith Estimate for your records.