No Surprises Act

OMB Control Number: 0938-1401

Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act

Under Section 2799B-6 of the Public Health Service Act and its implementing regulations, health care providers and health care facilities are required to inform individuals who are not enrolled in a group health plan, or group or individual health insurance coverage, or a Federal health care program, or a Federal Employees Health Benefits (FEHB) program health benefits plan (uninsured individuals), or not seeking to file a claim with their group health plan, health insurance coverage, or FEHB health benefits plan (self-pay individuals) in writing (and may also provide it orally, if an uninsured (or self-pay) individual requests a good faith estimate in a method other than paper or electronically), 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 and facilities to inform uninsured (or 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 items or services 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 estimate requirements to inform an individual of their rights to receive such a notice. Use of this model notice is not required and is provided as a means of facilitating compliance with the applicable notice requirements.

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, including the HHS interim final rules (IFR) titled Requirements Related to Surprise Billing; Part II, published on October 7, 2021.

Health care providers and facilities should not include these instructions with the documents given to patients.