Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities
are required to provide a good faith estimate of expected charges for items and services to individuals
who are not enrolled in a health insurance plan, coverage of a Federal health care program, or not seeking to file a
claim with their plan or coverage both orally and in writing, upon request or at the time of scheduling health care items and services. 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.

Please do not copy or duplicate these forms.
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