No Surprise Act Notice to Self-Pay Patients

This notice applies to Self-Pay Patients, which include the following:

• Patients with no health insurance coverage

• Patients who have health insurance coverage, but do not intend to have their insurance billed for reimbursement of services

• Patients with health insurance coverage, but no coverage or benefits for the services rendered

• Patients with health insurance coverage that does not offer any out-of-network provider coverage

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

The law requires health care providers to provide an estimated cost of medical care to patients who do not have insurance and patients who elect not to utilize their health insurance coverage and benefits.

Your rights include:

• The right to receive a Good Faith Estimate for the total expected cost of any nonemergency items or services prior to the care or item being delivered. This may include items such as, medical or diagnostic tests, prescription drugs, equipment, or hospital fees.

• You may also ask your health care provider before scheduling your care or receiving a medical item.

• If you receive a medical bill that is at least $400 more than your Good Faith Estimated amount, you may dispute the bill.

• Make sure to save a copy of your Good Faith Estimate.

For questions or if you need more information about your rights to a Good Faith Estimate, please visit: www.cms.gov/nosurprises or you may call our office by visiting our Contact Us page.