Good Faith Estimate

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                                                 Disclaimer

This Good Faith Estimate shows the costs of items and services that are

reasonably expected for your health care needs for an item or service. The

estimate is based on information known at the time the estimate was created.

The Good Faith Estimate does not include any unknown or unexpected costs

that may arise during treatment. You could be charged more if complications or

special circumstances occur. If this happens, federal law allows you to dispute

(appeal) the bill.

If you are billed for more than this Good Faith Estimate, you have

the right to dispute the bill.

You may contact the health care provider or facility listed to let them know the

billed charges are higher than the Good Faith Estimate. You can ask them to

update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask

if there is financial assistance available.

You may also 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 (about 4

months) of the date on the original bill.

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 Good Faith

Estimate. If the agency disagrees with you and agrees with the health care

provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to

www.cms.gov/nosurprises or call  call 1-800-985-3059 

For questions or more information about your right to a Good Faith Estimate

or the dispute process, visit www.cms.gov/nosurprises or call  call 1-800-985-3059