Good Faith Estimate

OMB Control Number [0938-XXXX]

Expiration Date: December 31, 2023

You have the right to receive a “Good Faith Estimate” explaining how much your medical care may cost at Northern Wyoming Surgical Center (NWSC).

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency item(s) or service provided at NWSC. This estimate may include a related range of cost of your surgery, such as facility fees. For any additional labs or tests, anesthesia and/or your medical provider fees, we can provide you telephone information in which you may contact these entities to obtain their estimated range of costs as well.

NWSC will provide a Good Faith Estimate either

If you receive a bill that is at least $400 more than your Good Faith Estimate, you may dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 307-587-2139.