Heartland Health Services Tax ID: 37-1270794

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 you save a copy or take a photo 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 HHS Regional Office at: 877-696-6775

This Good Faith Estimate (GFE) shows the cost of items and services that are reasonably expected for your health care needs. The estimate is based on information known at the time the estimate was created.

The GFE does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed for more than this GFE, you have the right to dispute the bill.  

You may contact the health care provider or facility listed to let them know the billed charges are higher than the GFE. You can ask them to update the bill to match the GFE, ask them to negotiate the bill, or ask if there is financial assistance available. 

If you are billed more than $400 above the amount on this GFE, you may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. 

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. 

_{To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call the HHS Regional Office at 877-696-6775}

_{For questions or more information about your right to a Good Faith Estimate or the dispute process, go to www.cms.gov/nosurprises or call the HHS Regional Office at: 877-696-6775}

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