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    rhecsw@optonline.net | 201-445-0550

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    Good Faith Estimate

    Appendix D: Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges”

    Below is a sample notice to be posted in a provider’s office and on a provider’s website:

    You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

    • Under the law, health care providers need to 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 of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
    • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose for a Good Faith Estimate before you schedule an item or 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 or picture 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 800-985-3059.

    300 Main St 21 #117
    Madison, NJ 07940

    201-445-0550
    rhecsw@optonline.net

    Now Offering Online & Teletherapy

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    R. Hope Eliasof
    rhecsw@optonline.net | 201-445-0550

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