Good Faith Estimate Notice

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 one 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.

Ask for a Good Faith Estimate when you schedule care, or at any time before your visit, by calling us or speaking with our team at the clinic. If you schedule care at least three business days in advance, you will receive your estimate within one business day. If you schedule at least ten business days in advance, you will receive it within three business days.

If you receive a bill that is substantially higher than your Good Faith Estimate, you can dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate, ask them to update the bill to match the estimate, ask to negotiate the bill, or ask whether financial assistance is available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). You must start the dispute process within 120 calendar days (about four months) of the date on the original bill. A fee applies to use the dispute process; if the agency reviewing your dispute agrees with you, you will have to pay the price on the Good Faith Estimate. Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises.

TMS Boulder, 1919 14th St, Suite 700, Boulder, CO 80302. (720) 833-4948