No Surprises Act notice

Your right to receive a Good Faith Estimate

If you do not have insurance or are not using insurance, you have the right to receive a Good Faith Estimate explaining how much your scheduled health care items and services are expected to cost.

When You Can Receive an Estimate

• You may ask for a Good Faith Estimate before scheduling care.
• If you schedule care at least 3 business days in advance, you should receive an estimate in writing.
• If you schedule care 10 or more business days in advance, you should receive an estimate within 3 business days.
• Good Faith Estimates generally do not apply to emergency care.

What the Estimate Includes

A Good Faith Estimate lists expected charges for the health care items and services reasonably expected for your scheduled care from this provider. It may not include services that are scheduled separately or provided by other providers.

Disputing a Bill

If you receive a bill that is at least $400 more than your Good Faith Estimate from a provider or facility, you may be able to dispute the bill through the federal patient-provider dispute resolution process.

Request an Estimate

Call Northwest Pediatrics & Adolescent Medicine at 541.386.2300. You can learn more at CMS.gov.