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

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Please review the above referenced document at https://docs.google.com/document/d/1xMYDMb3X6aJaivioGas14xyQ4_LK1a51n3XB48xPEFE/edit?usp=sharing

Completing the form below will serve as acknowledgement and acceptance of the above referenced document, as required by the No Surprises Act

The undersigned understands that he/she/they has the right to:

1) Receive a copy of this consent
2) Withdraw this consent at any time

This signed Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act will be saved in the medical record.

Name of patient: *

Name of parent/guardian (if patient under age of 18 years old):

Patient date of birth *

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