This “good faith” estimate shows that costs of services that are reasonably expected for your healthcare needs. This estimate is based on the information known at the time the estimate was created. The estimate 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 the bill. If you are billed for significantly more than this “good faith” estimate, you have the right to dispute the bill. You can contact us and notify that the charges are higher than the “good faith” estimate and ask us to update the bill or the estimate. You can 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 process within 120 calendar days 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 “good faith” estimate. If the agency disagrees with you and agrees with the provider, 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 1-877-696-6775.