Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under federal law, healthcare providers must give patients who don’t have insurance, or who are not using insurance, an estimate of the expected charges for medical services.
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You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency services. This includes related costs such as medical tests, equipment, or therapy sessions.
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Your provider will give you a written Good Faith Estimate at least one (1) business day before your scheduled appointment or service. You may also request a Good Faith Estimate at any time before booking an appointment.
If you receive a bill that is $100or more than your Good Faith Estimate, you have the right to dispute the bill.
Be sure to keep a copy or photo of your Good Faith Estimate for your records.
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Disclaimers
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You may be recommended additional services or items as part of your care that must be scheduled or requested separately and are not reflected in this Good Faith Estimate.
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This estimate reflects what is reasonably expected at the time it is issued. Actual services, items, or charges may differ depending on your individual treatment needs.
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You have the right to initiate a patient–provider dispute if the actual billed charges are substantially higher than the expected charges included in your estimate. Please contact our office for information on how to begin this process. Doing so will not affect the quality of care you receive.
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A Good Faith Estimate is not a contract and does not require you to receive services from any of the providers or facilities listed.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or contact our office:
Restore PT and Wellness
Phone: (662) 426-1001
Email: cfhill816@restorept.org