No Surprises Notice

Rebecca A. Eldredge, PhD, PLLC

810 Cottageview Drive, Ste. 102, Traverse City, MI 49684

(231)714-4840, rebecca@rebeccaephd.com, www.rebeccaephd.com

STANDARD NOTICE

“Right to Receive a Good Faith Estimate of Expected Charges”

Under the No Surprises Act

• 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 one business day before your medical service or item. You can also ask your healthcare 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 (231)714-4840.