Federal IDR Process for Air Ambulance Services

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OMB Control Number: 1210-0169
Expiration Date: 04/30/2022

Appendix 2
Standard Form: “Good Faith Estimate for Health Care Items and Services” Under the No
Surprises Act
(For use by health care providers, facilities, and providers of air ambulance services no later than
January 1, 2022)
Instructions
Under Section 2799B-6 of the Public Health Service Act and its implementing regulations, health care
providers, health care facilities, and providers of air ambulance services are required to provide a good
faith estimate of expected charges for items and services to individuals who are not enrolled in a group
health plan or group or individual health insurance coverage, or a Federal health care program, or a
Federal Employees Health Benefits (FEHB) program health benefits plan (uninsured individuals) or not
seeking to file a claim with their group health plan, health insurance coverage, or FEHB health benefits
plan (self-pay individuals) in writing (and may also provide it orally, if an uninsured (or self-pay)
individual requests a good faith estimate in a method other than paper or electronically), upon request or
at the time of scheduling health care items and services. For ease of reference, for purposes of this
document, the term “provider” should be considered to include providers of air ambulance services.
This form may be used by the health care providers and facilities to inform uninsured (or self-pay)
individuals of the expected charges for receiving certain health care items and services. A good faith
estimate must be provided within 3 business days upon request. Information regarding scheduled items
and services must be furnished within 1 business day of scheduling an item or service to be provided in
at least 3 business days; and within 3 business days of scheduling an item or service to be provided in at
least 10 business days.
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 expected charges. 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, including the HHS
interim final rules (IFR) titled Requirements Related to Surprise Billing; Part II, published on October
7, 2021.
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 1210-0169. 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
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.

[NAME OF CONVENING PROVIDER OR CONVENING FACILITY]

Good Faith Estimate for Health Care Items and Services
Patient
Patient First Name
Patient Date of Birth:

Middle Name

Last Name

____________/________/__________

Patient Identification Number:
Patient Mailing Address, Phone Number, and Email Address
Street or PO Box
City

Apartment
State

ZIP Code

Phone
Email Address
Patient’s Contact Preference:

[ ] By mail

[ ] By email

[ ] By phone

Patient Diagnosis
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

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Date of Good Faith Estimate:

____________/________/__________

Summary of Expected Charges
(See the itemized estimate attached for more detail.)
Provider Name

Estimated Total Cost

Provider Name

Estimated Total Cost

Provider Name

Estimated Total Cost

Total Estimated Cost: $

The following is a detailed list of expected charges for [LIST PRIMARY SERVICE
OR ITEM], scheduled for [LIST DATE[S] OF SERVICE, IF SCHEDULED] [[ADD
IF ADDITIONAL ITEMS/SERVICES ARE BEING INCLUDED], as well as for
items or services reasonably expected to be furnished in conjunction with the
primary item or service as part of the period of care]. [Include if items or services
are reoccurring, “The estimated costs are valid for 12 months from the date of the
Good Faith Estimate.”]

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[Provider/Facility 1] Estimate
Provider/Facility Name

Provider/Facility Type

Street Address
City

State

Contact Person

Phone

ZIP Code

Email

National Provider Identifier

Taxpayer Identification Number

Details of Services and Items for [Provider/Facility 1]
Service/Item

Address where service/item
will be provided

Diagnosis Code

Service Code

[Street, City, State, ZIP]

[ICD code]

[Service Code
Type: Service
Code Number]

Quantity

Expected Cost

Total Expected Charges from [Provider/Facility 1] $
Additional Health Care Provider/Facility Notes

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[Provider/Facility 2] Estimate [Delete if not needed]
Provider/Facility Name

Provider/Facility Type

Street Address
City

State

Contact Person

Phone

ZIP Code

Email

National Provider Identifier

Taxpayer Identification Number

Details of Services and Items for [Provider/Facility 2]
Service/Item

Address where service/item
will be provided

Diagnosis Code

Service Code

[Street, City, State, ZIP]

[ICD code]

[Service Code
Type: Service
Code Number]

Quantity

Expected Cost

Total Expected Charges from [Provider/Facility 2] $
Additional Health Care Provider/Facility Notes

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[Provider/Facility 3] Estimate [Delete if not needed]
Provider/Facility Name

Provider/Facility Type

Street Address
City

State

Contact Person

Phone

ZIP Code

Email

National Provider Identifier

Taxpayer Identification Number

Details of Services and Items for [Provider/Facility 3]
Service/Item

Address where service/item
will be provided

Diagnosis Code

Service Code

[Street, City, State, ZIP]

[ICD code]

[Service Code
Type: Service
Code Number]

Quantity

Expected Cost

Total Expected Charges from [Provider/Facility 3] $
Additional Health Care Provider/Facility Notes

Total estimated cost for all services and items: $
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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, and your bill is $400 or more for
any provider or facility than your Good Faith Estimate for that provider or facility,
federal law allows you to dispute the bill.

If you are billed for more than this Good Faith Estimate, you may
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.
If you dispute your bill, the provider or facility cannot move the bill for the
disputed item or service into collection or threaten to do so, or if the bill has
already moved into collection, the provider or facility has to cease collection
efforts. The provider or facility must also suspend the accrual of any late fees on
unpaid bill amounts until after the dispute resolution process has concluded. The
provider or facility cannot take or threaten to take any retributive action against
you for disputing your bill.
There is a $25 fee to use the dispute process. If the Selected Dispute Resolution
(SDR) entity reviewing your dispute agrees with you, you will have to pay the
price on this Good Faith Estimate, reduced by the $25 fee. If the SDR entity
disagrees with you and agrees with the health care provider or facility, you will
have to pay the higher amount.

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To learn more and get a form to start the process, go to
www.cms.gov/nosurprises/consumers 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/consumers, email
[email protected], 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.
PRIVACY ACT STATEMENT: CMS is authorized to collect the information on this
form and any supporting documentation under section 2799B-7 of the Public Health
Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the
Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the
form to process your request to initiate a payment dispute, verify the eligibility of
your dispute for the PPDR process, and to determine whether any conflict of interest
exists with the independent dispute resolution entity selected to decide your
dispute. The information may also be used to:
(1) support a decision on your
dispute; (2) support the ongoing operation and oversight of the PPDR program; (3)
evaluate selected IDR entity’s compliance with program rules. Providing the requested
information is voluntary. But failing to provide it may delay or prevent processing of your
dispute, or it could cause your dispute to be decided in favor of the provider or facility.

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