Federal IDR Process for Air Ambulance Services

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

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.

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

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
Street or PO Box

City

Apartment

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

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

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
Signature

Date

Print Name

PRIVACY ACT STATEMENT: CMS, pursuant to a delegation of authority from HHS, 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
this form to process a dispute to which you are a named party, verify the eligibility of the dispute for the PPDR process, and to
determine whether any conflict of interest exists with the dispute resolution entity selected to decide your dispute. The information
may also be used to: (1) support a decision on the dispute; (2) support the ongoing operation and oversight of the PPDR program;
and (3) evaluate the 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 the dispute, or it could cause the dispute to be resolved in favor of the other
party. If any person fails to provide correct information on this form or knowingly and willfully provide false or fraudulent
information, you may be subject to a penalty and other law enforcement action.
Get help in a language other than English. Information about how to access these services and help filling out the forms are
available by calling the Help Desk at 1-800-985-3059. TTY users can call 1-800-985-3059. You have the right to get this
information in an accessible format, like large print, Braille, or audio, at no cost to you. Call the Help Desk to request an accessible
format. You have the right to file a complaint if you feel you've been discriminated against. Visit https://cms.gov/about-cms/agencyinformation/aboutwebsite/cmsnondiscriminationnotice or call the Help Desk for more information at 1-800-985-3059. This product
was produced at U.S. taxpayer expense.

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

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
https://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/
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