Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

This Good Faith Estimate is only an estimate which may be subject to change and may not reflect the overall total charges. There may be additional items or services not contained in this Good Faith Estimate to be recommended by your provider as part treatment. If new or additional services are recommended for a future date, you will be provided with an updated Good Faith Estimate prior to that upcoming service.

If service(s) is/are recurring, then the estimated costs included on the Good Faith Estimate are valid for 12 months from the date of the Good Faith Estimate.

This Good Faith Estimate is not a contract, and you are not obligated to obtain the items and/or services mentioned on the estimate, you may decline services at any time, if you choose.

If the actual amount billed exceeds the expected charges included in this Good Faith Estimate by $400 or more, it is your individual right to initiate the patient-provider dispute resolution process.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.