Good Faith Estimate for Health Care Items and Services Form

Patient's Name *

First

Middle

Last

Patient's Date of Birth *

Patient's Identification Number *

Patient Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email Address *

Patient’s Contact Preference *

Primary Service or Item Requested/Scheduled *

Patient Primary Diagnosis *

Primary Diagnosis Code *

Patient Secondary Diagnosis

Secondary Diagnosis Code

If scheduled, list the date(s) the Primary Service or Item will be provided:

Check this box if this service or item is not yet scheduled

Date of Good Faith Estimate

Provider Name *

Estimated Total Cost *

Provider Name 2

Estimated Total Cost 2

Provider Name 3

Estimated Total Cost 3

Total Estimated Cost:

Total Estimated Cost *

The following is a detailed list of expected charges:

Expected Service *

Quantity (#) *

Cost (each) *

Total Cost *

Expected Service 2

Quantity (#) 2

Cost (each) 2

Total Cost 2

Expected Service 3

Quantity (#) 3

Cost (each) 3

Total Cost 3

Expected Service 4

Quantity (#) 4

Cost (each) 4

Total Cost 4

The estimated costs are valid for 12 months from the date of the Good Faith Estimate

Provider/Facility Estimate

Provider/Facility Name *

Provider/Facility Type *

Address *

Address Line 1

City

State

Zip Code

Contact Person *

Phone *

Email *

National Provider Identifier *

Taxpayer Identification Number *

Details of Services and Items for Provider/Facility

Service/Item *

Address where service/item will be provided *

Diagnosis Code *

Service Code *

Quantity *

Expected Cost *

Service/Item

Address where service/item will be provided

Diagnosis Code

Service Code

Quantity

Expected Cost

Service/Item

Address where service/item will be provided

Diagnosis Code

Service Code

Quantity

Expected Cost

Total Expected Charges from Provider/Facility:

Total Expected Charges from [Provider/Facility *

Total Estimated Cost for All Services and Items:

Total estimated cost for all services and items *

Additional Health Care Provider/Facility Notes

Disclaimer

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

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). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 1-800-985-3059.

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

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

Total Estimated Cost:

Provider/Facility Estimate

Details of Services and Items for Provider/Facility

Total Expected Charges from Provider/Facility:

Total Estimated Cost for All Services and Items:

Disclaimer

About Shurmatz Counseling

Cheektowaga Office

Amherst Office

West Seneca Office