Form CMS-10791 Right to Receive a Good Faith Estimate of Expected Charg

OMB Control Number: 0938-NEW
Expiration Date: XX/XXXX

Appendix 1
Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” 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 1 and health care facilities are required to inform 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), 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 and facilities to inform uninsured (or 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 items or services 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.
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.

For ease of reference, for purposes of this document, the term “provider” should be considered to include providers of air
ambulance services.

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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.

You have the right to receive a “Good Faith Estimate”
explaining how much your health care will cost
Under the law, health care providers need to give patients who don’t have certain types of
health care coverage or who are not using certain types of health care coverage an
estimate of their bill for health care items and services before those items or services are
provided.

• You have the right to receive a Good Faith Estimate for the total expected cost of

any health care items or services upon request or when scheduling such items or
services. This includes related costs like medical tests, prescription drugs,
equipment, and hospital fees.

• If you schedule a health care item or service at least 3 business days in advance,

make sure your health care provider or facility gives you a Good Faith Estimate in
writing within 1 business day after scheduling. If you schedule a health care item or
service at least 10 business days in advance, make sure your health care provider
or facility gives you a Good Faith Estimate in writing within 3 business days after
scheduling. You can also ask any health care provider or facility for a Good Faith
Estimate before you schedule an item or service. If you do, make sure the health
care provider or facility gives you a Good Faith Estimate in writing within 3
business days after you ask.

• If you receive a bill that is at least $400 more for any provider or facility than your
Good Faith Estimate from that provider or facility, you can dispute the bill.

For questions or more information about your right to a Good Faith Estimate, visit

www.cms.gov/nosurprises/consumers, email [email protected], or call 1-

800-985-3059.

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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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