N/A (facility-specific) · Hospitals / Surgery Centers / Providers
Good Faith Estimate receipt and acknowledgment for scheduled services. Under the No Surprises Act, uninsured or self-pay patients must receive a cost estimate at least 3 business days before scheduled items or services.
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Provided by the facility's financial counselor or billing department
Mailed to the patient before the scheduled procedure
Available through the provider's patient portal or price transparency tool
Filing Deadline
Under the No Surprises Act, providers must give uninsured/self-pay patients a Good Faith Estimate at least 3 business days before a scheduled service.
Immediate upon acknowledgment. This is an informational document — signing does not commit you to the procedure.
If the final bill exceeds the Good Faith Estimate by $400 or more, you may be eligible to dispute the bill through the patient-provider dispute resolution process. Keep your copy of the estimate for comparison.
N/A (facility-specific) · Hospitals / Providers
Authorization for the facility to provide medical treatment. Signed at registration or admission. Covers routine care, testing, and standard procedures.
N/A (facility-specific) · Hospitals / Providers
Specific consent for a procedure or surgery, documenting that risks, benefits, alternatives, and potential complications were explained and understood by the patient.
N/A (facility-specific) · Hospitals / Surgery Centers
Comprehensive surgical consent documenting the specific procedure, surgeon, risks, benefits, alternatives, and acknowledgment of anesthesia requirements. May include consent for blood products and tissue examination.
N/A (facility-specific) · Hospitals / Surgery Centers
Separate consent acknowledging risks specific to anesthesia administration, including the type of anesthesia planned and associated complications.
N/A (facility-specific) · Hospitals / Providers
Documents patient's decision to refuse recommended treatment or leave the facility against medical advice, acknowledging potential risks and consequences.
FAP Application (hospital-specific) · 501(c)(3) Nonprofit Hospitals
Application for charity care / financial assistance based on income and family size. Under IRS Section 501(r), nonprofit hospitals must have a written Financial Assistance Policy, widely publicize it, and make applications available for free.
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