You have the right to receive a
"Good Faith Estimate"
explaining how much your medical care will cost
Under the law, Health Services, Inc. will give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost on any non-emergency items or services. This includes costs like medical tests, prescription drugs, equipment, and hospital fees.
HSI will provide you a Good Faith Estimate within one business day before your scheduled medical service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 334-420-5001.
Please submit your completed Good Faith Estimate request form to firstname.lastname@example.org.