Good Faith Estimate

OMB Control Number: 0938-1401
Expiration Date: 03/31/2022
Standard Notice and Consent Documents Under the No Surprises Act

(For use by nonparticipating providers and nonparticipating emergency facilities beginning
January 1, 2022)
Instructions
The Department of Health and Human Services (HHS) developed standard notice and consent
documents under section 2799B-2(d) of the Public Health Service Act (PHS Act). These
documents are for use when providing items and services to participants, beneficiaries,
enrollees, or covered individuals in group health plans or group or individual health insurance
coverage, including Federal Employees Health Benefits (FEHB) plans by either:
• A nonparticipating provider or nonparticipating emergency facility when furnishing
certain post-stabilization services, or
• A nonparticipating provider (or facility on behalf of the provider) when furnishing non-
emergency services (other than ancillary services) at certain participating health care
facilities.
These documents provide the form and manner of the notice and consent documents specified
by the Secretary of HHS under 45 CFR 149.410 and 149.420. HHS considers use of these
documents in accordance with these instructions to be good faith compliance with the notice
and consent requirements of section 2799B-2(d) of the PHS Act, provided that all other
requirements are met. To the extent a state develops notice and consent documents that meet
the statutory and regulatory requirements under section 2799B-2(d) of the PHS Act and 45 CFR
149.410 and 149.420, the state-developed documents will meet the Secretary’s specifications
regarding the form and manner of the notice and consent documents.
These documents may not be modified by providers or facilities, except as indicated in brackets
or as may be necessary to reflect applicable state law. To use these documents properly, the
nonparticipating provider or facility must fill in any blanks that appear in brackets with the
appropriate information. Providers and facilities must fill out the notice and consent documents
completely and delete the bracketed italicized text before presenting the documents to
patients.
In particular, providers and facilities must fill in the blanks in the “Estimate of what you may
pay” section and the “More details about your estimate” section before presenting the
documents to patients.
The standard notice and consent documents must be given physically separate from and not
attached to or incorporated into any other documents. The documents must not be hidden or
included among other forms, and a representative of the provider or facility must be physically
present or available by phone to explain the documents and estimates to the individual, and
answer any questions, as necessary. The documents must meet applicable language access
requirements, as specified in 45 CFR 149.420. The provider or facility is responsible for2
translating these documents or providing a qualified interpreter, as applicable, when necessary
to meet those requirements. The standard notice must be provided on paper, or, when
feasible, electronically, if selected by the individual. The individual must be provided with a
copy of the signed consent document in-person, by mail or via email, as selected by the
individual.
If an individual makes an appointment for the relevant items or services at least 72 hours
before the date that the items and services are to be furnished, these notice and consent
documents must be provided to the individual, or the individual’s authorized representative, at
least 72 hours before the date that the items and services are to be furnished. If the individual
makes an appointment for the relevant items or services within 72 hours of the date the items
and services are to be furnished, these notice and consent documents must be provided to the
individual, or the individual’s authorized representative, on the day the appointment is
scheduled. In a situation where an individual is provided the notice and consent documents on
the day the items or services are to be furnished, including for post-stabilization services, the
documents must be provided no later than 3 hours prior to furnishing the relevant items or
services.
NOTE: The information provided in these instructions is intended to be only 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. Refer to the applicable statutes,
regulations, and other interpretive materials for complete and current information.
Do not include these instructions with the standard notice and consent documents given to
patients.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid Office of Management and Budget (OMB)
control number. The valid OMB control number for this information collection is 0938-1401.
The time required to complete this information collection is estimated to average 1.3 hours per
response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-
05, Baltimore, Maryland 21244-1850.

What does this mean for you?

The Good Faith Estimate is to help reduce unexpected medical expenses. As a provider, I will give you a Good Faith Estimate when you inquire about services. As a private pay provider, I do not offer out of network benefits and the cost of 45 minute therapy sessions will be the same cost each session. There is never any additional charges for diagnostic code changes. In the event that treatment changes based on collaborative needs, a new Good Faith Estimate may be reassessed.