Health Care Facilities on Behalf of Health Care Providers and Health Care Facilities

Requirements Related to No Surprise Billing Act, Part II (CMS-10791)

1. Right to Receive a Good Faith Estimate of Expected Charges Notice

Health Care Facilities on Behalf of Health Care Providers and Health Care Facilities

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Appendix 1

OMB Control Number [XXXX-XXXX]
Expiration Date [MM/DD/YYYY]

Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” Under the No
Surprises Act
(For use by health care providers no later than January 1, 2022)
Instructions
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities
are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care
program, or not seeking to file a claim with their plan or coverage both orally and in writing of their
ability, upon request or at the time of scheduling health care items and services, to receive a “Good
Faith Estimate” of expected charges.
This form may be used by the health care providers to inform individuals who are not enrolled in a plan
or coverage or a Federal health care program (uninsured individuals), or individuals who are enrolled
but not seeking to file a claim with their plan or coverage (self-pay individuals) of their right to a “Good
Faith Estimate” to help them estimate the expected charges they may be billed for receiving certain
health care items and services. Information regarding the availability of a “Good Faith Estimate”
must be prominently displayed on the convening provider’s and convening facility’s website and in
the office and on-site where scheduling or questions about the cost of health care occur.
To use this model notice, the provider or facility must fill in the blanks with the appropriate information.
HHS considers use of the model notice to be good faith compliance with the good faith estimate
requirements to inform an individual of their rights to receive such a notice. Use of this model notice is
not required and is provided as a means of facilitating compliance with the applicable notice
requirements. However, some form of notice, including the provision of certain required information, is
necessary to begin the patient-provider dispute resolution process.
NOTE: The information provided in these instructions is intended only to be a general informal
summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or
formal policy guidance upon which it is based. Readers should refer to the applicable statutes,
regulations, and other interpretive materials for complete and current information. [Link to IFR when
available.]
Health care providers and facilities should not include these instructions with the documents given
to patients.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are 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 0938-XXXX. The time required to
complete this information collection is estimated to average 1.3 hours per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or

OMB Control Number [XXXX-XXXX]
Expiration Date [MM/DD/YYYY]

suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

OMB Control Number [XXXX-XXXX]
Expiration Date [MM/DD/YYYY]

You have the right to receive a “Good Faith Estimate”
explaining how much your medical care will cost
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.

• You have the right to receive a Good Faith Estimate for the total
expected cost of any non-emergency items or services. This includes
related costs like medical tests, prescription drugs, equipment, and
hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate
in writing at least 1 business day before your medical service or item.
You can also ask your health care provider, and any other provider you
choose, for a Good Faith Estimate before you schedule an item or
service.
• If you receive a bill that is at least $400 more than your Good Faith
Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit
www.cms.gov/nosurprises or call [INSERT PHONE NUMBER].

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File Typeapplication/pdf
File TitleRight to Receive a Good Faith Estimate of Expected Charges Notice
File Modified2021-09-24
File Created2021-09-23

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