Good Faith Estimate

You have the right to request a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to offer 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 request a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests and prescription drug.

Make sure you request a Good Faith Estimate in writing at least 3-10 business days 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, call 1 (844) 900-WELL, or email estimates@vpchc.org.

Good Faith Estimate

First Name*
Last Name*
Email*
Date of Birth or Account Number*
Date of Appointment*
MM slash DD slash YYYY
Reason for Visit*
How do you wish to receive an estimate?*
Are you using insurance for this visit?*
- Yes
- No
Are you interested in receiving Sliding Fee Scale information?*
- Yes
- No
Consent*
I agree
By clicking this button, you agree to receive this estimate electronically through the method chosen, and to the email address provided above.
Comments
This field is for validation purposes and should be left unchanged.

What is Sliding Fee Scale?

If a patient is uninsured or underinsured, a sliding fee scale is available for patients to receive a discounted rate.

Learn More