(OMB Control Number [XXX-XXX])

Expiration Date [MM/DD/YYYY]

Appendix 1

Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act

(For use by health care providers no later than January 1, 2022)

Instructions

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage, both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.