This good faith estimate is an estimate only for the service/procedure listed and may not be the final amount due. Should the provider/facility deem it medically necessary to increase/change your level of care, your financial obligation may differ from what is shown.

Please Note: this is a hospital estimate only and does not include physician or other professional provider fees. Actual total charges could increase or decrease depending on what may be required to carry out your care.

Additional items and/or services that are not in this good faith estimate may be recommended by the convening provider as part of the course of care, such as rehabilitation therapies or other post treatment items or services. Those services must be scheduled separately and are not reflected in this good faith estimate.

You have the right to initiate the patient-provider dispute process if the actual charges differ significantly from this good faith estimate.

This good faith estimate is not a contract and does not require the named individual to obtain the items and services from any of the providers or facilities identified on this good faith estimate.

I have read and understand the above disclaimer and limitations. I fully understand this is only an estimate and my actual charges may be different from the good faith estimate.

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Agree and continue to obtain your estimation