Appendix 1
Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act
(For use by health care providers no later than January 1, 2022)
Instructions
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are 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 “Good Faith Estimate” of expected charges.
This form may be used by the health care providers to inform individuals who are not enrolled in a plan or coverage or a Federal health care program (uninsured individuals), or individuals who are enrolled but not seeking to file a claim with their plan or coverage (self-pay individuals) of their right to a “Good Faith Estimate” to help them estimate the expected charges they may be billed for receiving certain health care items and services. Information regarding the availability of a “Good Faith Estimate” must be prominently displayed on the convening provider’s and convening facility’s website and in the office and on-site where scheduling or questions about the cost of health care occur.
To use this model notice, the provider or facility must fill in the blanks with the appropriate information. HHS considers use of the model notice to be good faith compliance with the good faith estimaterequirements to inform an individual of their rights to receive such a notice. Use of this model notice isnot required and is provided as a means of facilitating compliance with the applicable notice
requirements. However, some form of notice, including the provision of certain required information, is necessary to begin the patient-provider dispute resolution process.
NOTE: The information provided in these instructions is intended only to be a general informal
summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance upon which it is based. Readers should refer to the applicable statutes,
regulations, and other interpretive materials for complete and current information. [Link to IFR when available.]
Health care providers and facilities should not include these instructions with the documents given to patients.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-XXXX. The time required to
complete this information collection is estimated to average 1.3 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or
OMB Control Number [XXXX-XXXX] Expiration Date [MM/DD/YYYY]suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.