Good Faith Estimate Notice

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 expected charges for medical services
• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency medical services

• You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a 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 1-800-985-3059.

Indiana Residents

A patient may ask for an estimate of the amount the patient will be charged for medical services provided by Within Health. Indiana law requires that such estimate be provided within 5 business days of the request.