Patient Billing Rights

In accordance with the “No Surprises Act”, Section 2799B-6 of the Public Health Service Act, set to go into effect 01/01/2022, healthcare providers are required to provide a “good faith” estimate of expected charges for services to individuals not enrolled in a plan or coverage or a federal health program, both orally and in writing. This paperwork serves as an in writing “good faith” estimate for services rendered.

The form may be used by the health care providers to inform individuals who are not enrolled in a plan or coverage or a Federal health care program (uninsured individuals), or individuals who are enrolled but not seeking to file a claim with their plan or coverage (self-pay individuals) of the expected charges they may be billed for receiving certain health care items and services. A good faith estimate must be provided within 3 business days upon request. Information regarding scheduled items and services must be furnished within 1 business day of scheduling an item or service to be provided in 3 business days; and within 3 business days of scheduling an item or service to be provided in at least 10 business days.

** Given the nature of therapy services, typically exact estimates are difficult to predict due to not knowing severity of symptoms, recommended frequency of services, length of time of services, and any other variables.**

Disclaimer

This “good faith” estimate shows that costs of services that are reasonably expected for your healthcare needs. This estimate is based on the information known at the time the estimate was created. The 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 the bill. If you are billed for significantly more than this “good faith” estimate, you have the right to dispute the bill.

You can contact us and notify that the charges are higher than the “good faith” estimate and ask us to update the bill or the estimate. You can 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 process within 120 calendar days 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 provider, 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 or call 1- 877-696-6775.