OMB Control Number 1210-0169]
ExpirationDate [12/31/2022]
Associated Urologists PA /Associated Urologists ASC
Good Faith Estimate for Health Care Items and Services

1

Patient

Patient First Name	Middle Name	Last Name

Patient Date of Birth:	 	/ 	/ 	

Patient Identification Number:

Patient Mailing Address, Phone Number, and Email Address

Street or PO Box	Apartment

City	State	ZIP Code

Phone

Email Address

Patient’s Contact Preference:	[  ] By mail	[  ] By email

Patient Diagnosis

Primary Service or Item Requested/Scheduled

Patient Primary Diagnosis	Primary Diagnosis Code

Patient Secondary Diagnosis	Secondary Diagnosis Code

Summary of Expected Charges
(See the itemized estimate attached for more detail.)

OMB Control Number 1210-0169
ExpirationDate 12/31/2022

The following is a detailed list of expected charges for [LIST PRIMARY SERVICE OR ITEM], scheduled for [LIST DATE OF SERVICE, IF SCHEDULED]. [Include if items or services are reoccurring, “The estimated costs are valid for 12 months from the date of the Good Faith Estimate.”]

2

If scheduled, list the date(s) the Primary Service or Item will be provided:

[ ] Check this box if this service or item is not yet scheduled

Date of Good Faith Estimate:	 	/ 	/ 	

Provider Name	Estimated Total Cost

Provider Name	Estimated Total Cost

Provider Name	Estimated Total Cost

Total Estimated Cost: $

Total Expected Charges from Associated Urologists PA/Associated Urologists ASC $

Associated Urologists PA /Associated Urologists ASC

OMB Control Number1210-0169
ExpirationDate 12/31/2022

Details of Services and Items for [Provider/Facility 1]

3

Additional Health Care Provider/Facility Notes

Service/Item

Address where service/item will be provided

Diagnosis Code

Service Code

Quantity

Expected Cost

[Street, City, State, ZIP]

[ICD code]

[Service Code Type: Service Code Number]

Provider/Facility Name	Provider/Facility Type

Street Address

City	State	ZIP Code

Contact Person	Phone	Email

National Provider Identifier	Taxpayer Identification Number

Details of Services and Items for Associated Urologists PA //Associated Urologists ASC 

Associated Urologists PA /Associated Urologists ASC Estimate

OMB Control Number 1210-0169
ExpirationDate 12/31/2022

4

Service/Item

Address where service/item will be provided

Diagnosis Code

Service Code

Quantity

Expected Cost

[Street, City, State, ZIP]

[ICD code]

[Service Code Type: Service Code Number]

Provider/Facility Name	Provider/Facility Type

Street Address

City	State	ZIP Code

Contact Person	Phone	Email

National Provider Identifier	Taxpayer Identification Number

Total Expected Charges from Associated Urologists PA/Associated Urologists ASC  2] $

OMB Control Number 1210-0169
ExpirationDate 12/31/2031

5

Additional Health Care Provider/Facility Notes

Associated Urologists PA/Associated Urologists ASC Facility 3] Estimate

OMB Control Number 1210-0169
ExpirationDate 12/31/2022

Details of Services and Items for [Provider/Facility 3]

6

Total Expected Charges from [Provider/Facility 3]$

Service/Item

Address where service/item will be provided

Diagnosis Code

Service Code

Quantity

Expected Cost

[Street, City, State, ZIP]

[ICD code]

[Service Code Type: Service Code Number]

Provider/Facility Name	Provider/Facility Type

Street Address

City	State	ZIP Code

Contact Person	Phone	Email

National Provider Identifier	Taxpayer Identification Number

OMB Control Number 1210-0169
ExpirationDate 12/31/2022

7

Total estimated cost for all services and items: $

Additional Health Care Provider/Facility Notes

OMB Control Number 1210-0169
ExpirationDate 12/31/2022

Disclaimer

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

The Good Faith 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 (appeal) the bill.

If you are billed for more than this Good Faith Estimate, you have the right to 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. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may 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 dispute process within 120 calendar days (about 4 months) 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 health care provider or facility, 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/consumers or call 1-800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call
1-800-985-3059.

8

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.