Good Faith Estimate

Good Faith Notice

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Surprise Billing Protection Form

This document describes your protections against unexpected medical bills. It also asks if you’d like to give up those protections and pay more for out-of-network care.

 

IMPORTANT: You aren’t required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider before scheduling care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less.

If you’d like assistance with this document, ask your provider or a patient advocate. Take a picture and/or keep a copy of this form for your records.

You’re getting this notice because this provider or facility isn’t in your health plan’s network and is considered out-of-network. This means the provider or facility doesn’t have an agreement with your plan to provide services. Getting care from this provider or facility will likely cost you more.

If your plan covers the item or service you’re getting, federal law protects you from higher bills when:

• You’re getting emergency care from an out-of-network provider or facility, or

• An out-of-network provider is treating you at an in-network hospital or ambulatory surgical

center without getting your consent to receive a higher bill.

Ask your health care provider or patient advocate if you’re not sure if these protections apply to you.

If you sign this form, be aware that you may pay more because:

• You’re giving up your legal protections from higher bills.

• You may owe the full costs billed for the items and services you get.

• Your health plan might not count any of the amount you pay towards your deductible and out-

of-pocket limit. Contact your health plan for more information.

Before deciding whether to sign this form, you can contact your health plan to find an in-network

provider or facility. If there isn’t one, you can also ask your health plan if they can work out an

agreement with this provider or facility (or another one) to lower your costs.

 

Good Faith Estimate

 

Estimate of what you could pay if you give up your protections

 

Total cost estimate of what you may be asked to pay:

 

►Review your detailed estimate. 

 

►Call your health plan. Your plan may have better information about how much you’ll be asked to pay.

 

You also can ask about what’s covered under your plan and your provider options.

 

►Questions about this notice and estimate? Contact 586-932-2700

 

►Questions about your rights? Contact 1-800-985-3059

 

Prior authorization or other care management limitations

 

Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover the items or services before you can get them. If your plan requires prior authorization, ask them what information they need for you to get coverage.

 

Understanding your options

 

You can get the items or services described in this notice from the following providers who are in-network with your health plan:

 

More information about your rights and protections

Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.OMB Control Number: 0938-1401 Expiration Date: 05/31/2025