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.
- 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.
- 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.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- 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.
Below are our Good Faith Forms with Self-Pay amounts. There are also Good Faith Forms with our ChiroHealth USA discount amounts. ChiroHealth USA does require a $49 yearly enrollment to receive the discount on our services.
Good Faith Estimate Self Pay
Good Faith Estimate New Patient Self Pay
Good Faith Estimate DRX Self Pay
Good Faith Estimates with ChiroHealth USA
Good Faith Estimate New Patient CHUSA
Good Faith Estimate DRX CHUSA
Good Faith Estimates Medicare
Good Faith Estimate New Patient Medicare
Good Faith Estimate New Patient Medicare with CHUSA
Good Faith Estimate Existing Patient Medicare
Good Faith Estimate Existing Patient Medicare with CHUSA
Good Faith Estimate Extra Spinal Medicare
Good Faith Estimate Extra Spinal Medicare with CHUSA