Federal IDR Process for Services relating to Nonparticipating Providers or Nonparticipating Emergency Facilities

OMB Control Number: 0938-NEW

Expiration Date: XX/XXXX

APPENDIX 4

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 https://www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

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.

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. Note: As an Authorized Representative, if you submit the PPDR form to initiate a payment dispute, you represent that you are authorized to initiate the dispute on behalf of the patient who received the services at issue in the dispute, or by another party responsible for paying for the services at issue in the payment dispute (such as the patient’s parent, guardian or court-appointed representative.
Mailing Address and Phone Number
Street or PO Box		Apartment
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

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 ZIP

Email Phone

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. Payment is required to start the dispute process. Please note personal checks or cash will not be accepted. Accepted forms of payment are: cashier’s check, money order, or electronic payment such as credit card, debit card, or payment apps.

• 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

Iattest to the best of my knowledge and belief, the information I have provided is true and accurate.

Signature Date

Print Name

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

• Your $25 Administrative Fee (If mailing this form)

You can send this form and documents:

• Online

www.cms.gov/nosurprises/consumers

• By mail

C2C Innovative Solutions Inc,

Patient-Provider Dispute Resolution, P.O. Box 45105,

Jacksonville, FL, 32232-5105

• By fax

888-610-4092

For additional help call 1-800-985-3059 or e-mail [email protected]

When HHS receives this form, they will send you a link where you can electronically pay the fee to start the dispute process. If mailing this form, you can include a cashier’s check or money order with your form. Please do not send cash or personal checks as they will not be accepted.

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: https://www.cms.gov/nosurprises/consumers/consumers

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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