Good Faith Estimate for Healthcare Items and Services

Effective January 1, 2022, a ruling called the “No Surprises Act” (H.R. 133) requires practitioners to provide a “Good Faith Estimate” (GFE) for care for which a patient does not use insurance to pay for care. The GFE shows the cost of items and services reasonably expected for your health care needs, a diagnosis, and a reason for treatment. The estimate is based on information known when the estimate was created. The GFE does not include unknown or unexpected costs that may arise during treatment, and you could be charged more if the treatment plan is such that additional services or items are indicated or recommended by your provider. You will be provided a new GFE should this occur. If this happens, federal law allows you to dispute (appeal) the bill if you and your provider have not previously talked about the change and you have not been given an updated GFE.

Under Section 2799B-6 of the Public Health Service Act (PHSA), health care providers and health care facilities are required to inform individuals not enrolled in a plan or coverage or a Federal health care program or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request, or at the time of scheduling health care items and services to receive a “GFE” of expected charges.

Note: The PHSA and GFE do not currently apply to any patients who are using insurance benefits, including out-of-network benefits (i.e., submitting your care bills to insurance for reimbursement).

Your Financial Responsibility Summary: The amount you would owe for a visit, which may be new patient visit, a follow-up evaluation, a test, a procedure, a combination of the aforementioned, or other service(s) or item(s), depending upon the diagnosis, treatment plan, and other potential factors.
Disclaimer: Under the No Surprises Act, health care providers need to give patients 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 Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes (under the law/when applicable) related charges like medical tests, prescription drugs, equipment, and hospital fees.
  • If you receive a bill at least $400 more than your GFE, you can dispute the bill.
    • You may contact the health care provider or facility listed to let them know the billed charges are higher than the GFE. You can ask them to update the bill to match the Good Faith Estimate, negotiate the bill or ask if financial assistance is available.
    • You may start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (~ 4 months) of the original bill date.
    • There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
  • Make sure your health care provider gives you a GFE within the following timeframes:
    • If the service is scheduled at least three business days before the appointment date, no later than one business day after the date of scheduling;
    • If the service is scheduled at least ten business days before the appointment date, no later than three business days after the date of scheduling; or
    • If the uninsured or self-pay patient requests a GFE (without scheduling the service), no later than 3 business days after the date of the request. A new GFE must be provided within the specified timeframes if the patient reschedules the requested item or service.
  • The No Surprises Act has a universal waiver form required — which RELIEVE – Pain and Spine Center has adapted into this form. You may view the PDF of the waiver at:
  • This is the public disclosure of the “Good Faith Estimate.”

Note: A Good Faith Estimate is for your awareness only. It does NOT involve you needing to make any commitment.

To learn more and get a form to start the process, go to or call 800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit or call 800-985-3059. Please keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

This form does not have to be signed. However, you have 24 hours from the time of delivery of this form to you (delivery is time-stamped in the portal) to raise concerns or inquiries regarding the information included in this form. If communication is not received within 24 hours, this form will be considered understood and acknowledged in place of a signature. Receiving this form allows you to keep it for your permanent records.