OMB Control #: 0938-1401

You have the right to receive a Good Faith Estimate (GFE) explaining how much your medical care will cost.

Under the law, healthcare providers must give clients who do not have insurance or are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a GFE for the total expected cost of any services you are paying for out-of-pocket.

• Ensure your healthcare provider gives you the GFE in writing at least 1 business day before your medical service. You can also ask your provider, or any provider you choose, for a GFE before you schedule a service.

• You can dispute the bill if you receive a bill that is at least $400.00 more than your GFE.

• Make sure you save a copy or picture of your Good Faith Estimate.

For any questions, contact Korrine Wojcik, LCSW at kwojcik@korrinewojcik.com.

You can also visit www.cms.gov/nosurprises for more information.