OMB Control Number 0938-1401
Expiration Date 04/30/22
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.
1. 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.
2. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before
your medical service or item. You can also ask your
health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or
service.
3. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
4. 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 the Colorado Division of Insurance at 303-894-7499
or 1-800-930-3745.
Eclectic Therapy
Location
7955 East Arapahoe Court Suite #1425
Centennial, Colorado 80112