Form CMS-10791 Dispute Initiation Form

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Patient-Provider Dispute Resolution Form
Find out if you qualify for the dispute resolution process
This form is only for people who do not have health insurance or who
decided not to use insurance for their medical care.

Did your health care provider give you a Good Faith Estimate for
the item or service?

Yes

No

Is the bill for your health care provider at least $400 more than the
Good Faith Estimate?

Yes

No

Is the date on the top of the bill within the last 120 calendar days
(about 4 months)?

Yes

No

If you answered NO to any of these questions:
• You do not qualify for the dispute resolution process. Please contact your
health care provider to negotiate your bill and ask for financial assistance.
• If you think you should have been given a Good Faith Estimate or have
other questions, please visit www.cms.gov/nosurprises or call [insert HHS
number]

If you answered YES to ALL of these questions:

You qualify for the dispute resolution process. Please complete the rest of
this form.
Note: While the dispute resolution process is happening, you can still ask your
health care provider for a lower bill.

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Patient name (and Authorized Representative name, if needed)
Patient First Name

Middle Name

Last Name

(Optional) If you are filling out this form for the patient, please print your
name:
[ ] Check this box if you are an Authorized Representative and should be contacted instead
of the patient. Write your information in the “mailing address and phone number” section.
Note: This is common for patients under age 18 or patients who need help completing
medical forms.

Mailing Address and Phone Number
Apartment

Street or PO Box

City

State

ZIP

Phone

Details about the medical item or service you want to dispute
The State where the patient received the item or service:

The date when the patient received the item or service:
Month
Day
Year

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Write a short description of the item or service you want to dispute. (For
example, “knee replacement” or “cervical cancer screening”)

I have included with this form:
[ ] A copy of the bill from my health care provider that I want to dispute
[ ] A copy of the Good Faith Estimate for the item or service that I want to
dispute
Contact information for the health care provider that provided the item or
performed the service. This should be on your Good Faith Estimate.
Health Care Provider Name

Hospital, Facility, or Group Name

Street

City

State

Email

Phone

ZIP

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Read and sign
• I agree to let my health care provider to release all relevant medical or
treatment records related to this dispute, to a Selected Dispute
Resolution (SDR) entity and selected by the U.S. Department of Health
and Human Services (HHS). I understand the SDR entity will only use
this information to make a decision on this dispute. My information will be
kept confidential and not released to anyone else. If this information is
still needed after 1 year, I will be asked to release my information again.
• I agree to pay a $25 fee for the dispute process.
• When the SDR entity makes the decision about the price for these
medical items or services, I agree to pay the decided amount.
[ ] Check here to agree
Signature

Date

Print Name

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How to send this form
Make sure you have included:
• A copy of the bill from your health care provider or facility that you want
to dispute
• A copy of the Good Faith Estimate for the item or service that you want
to dispute
You can send this form and documents:
• Online
www.cms.gov/nosurprises
• By email
[HHS email]
• By mail
[SDR entity name]
Address
Address
For additional help call [HHS phone] or e-mail [HHS email]
When HHS receives this form, they will send you a link where you can pay the
fee to start the dispute process.

Keep a copy or take pictures of this completed form. You may need it later.
For more information about your right under federal law to dispute medical bills, visit:
www.cms.gov/nosurprises
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