Good Faith Estimate Acknowledgment (No Surprises Act)

# Good Faith Estimate Acknowledgment (No Surprises Act) This document is provided in compliance with the No Surprises Act (42 U.S.C. § 300gg-136) and implementing regulations at 45 C.F.R. Part 149. You are receiving this Good Faith Estimate (GFE) because you are uninsured, are electing not to use your insurance for these services, or have otherwise requested an estimate. This estimate is not a contract and does not require you to obtain the listed services from the provider identified above. --- ## Patient Information **Patient Name:** ___________ **Date of Birth:** ___________ **Address:** ___________ **Phone Number:** ___________ **Email Address:** ___________ --- ## Provider Information **Provider / Practice Name:** ___________ **National Provider Identifier (NPI):** ___________ **Address:** ___________ **Phone:** ___________ **Tax Identification Number (TIN):** ___________ --- ## Good Faith Estimate of Expected Charges The following table lists the services scheduled for you and our good faith estimate of the charges for each. These estimates are based on information available at the time this estimate was prepared and the services we reasonably expect to be provided. **Scheduled / Expected Date of Service:** ___________