In late 2021, the Department of Health and Human Services enacted provisions to ostensibly protect consumers from surprise bills, a leading cause of bankruptcy.

While the majority of bankruptcies are due to emergency medical care, air ambulance services, or surprise fees from hospitals, this law cumbersomely applies to all practitioners including clinics such as ours. This estimate is intended to provide you with the likely charges you may incur here. This document describes your protection against unexpected bills. You could pay more being seen in this facility than if you were to be seen in-network. You are entitled to seek care in-network and may contact your insurer to see if they contract with any competent providers within the area. You aren’t required to sign this form.

Contact your insurer to verify that we are in-network with your plan. If you are insured with one of our contracted plans, the below will only apply IF you ever find yourself without that insurance.

If you are uninsured or are being seen out of network (self-pay), we have recommended that you enroll, at no cost, with a contracted DMCO as this provides us our ONLY legal means to offer you a discounted fee schedule while still remaining compliant with our current insurance contracts and the labyrinth of federal and state laws related to medical billing.

Disclaimer: This Good Faith Estimate shows the costs of items and services that are reasonably expected based on your health care needs. The estimate is based on information known at the time the estimate was created. It 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 (appeal) the bill.

This Good Faith Estimate is not a contract and does not require you to obtain the services from the providers or facility identified in it. You have the right to request another Good Faith Estimate at any time during your course of care. If the actual billed service charges exceed this estimate by $400 or more, then you (the patient) have the right to dispute the bill via the patient-provider dispute resolution process with the U.S. Department of Health and Human Services (HHS). Please feel free to contact us first so that we may address any glaring discrepancy. If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) 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 health care provider or facility, you will have to pay the higher amount. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059

Initial Visit (defined as all patients NOT seen in the previous 3 years) Your initial visit will include an exam (99202-99205) and will likely include chiropractic manipulative therapy (98940-98942) and/or therapeutic exercise (97110) and/or manual therapy (97140).

Your subsequent visits will likely include a combination of chiropractic manipulative therapy (98940-98942) and/or therapeutic exericse (97110) and/or manual therapy (97140).

Reevaluations will include an exam (99212-99215) and will likely include chiropractic manipulative therapy (98940-98942) and/or therapeutic exercise (97110) and/or manual therapy (97140).

Despite the best intentions of the No Surprises Act, it is impossible for a clinic to fully gauge which services will be provided to a patient who has yet to be evaluated.

The above Good Faith Estimate is based on the most common conditions seen within our office (back pain, neck pain, sciatica, radiculopathy, extremity pain, headache, jaw pain, vertigo) and the services we most typically provide to treat those conditions.

If other services are provided, you will retain your protections to dispute your charges in the almost entirely impossible chance that your billing for any of the above described individual visits was off by greater than $400, although we cannot envision a scenario where that would be mathematically possible. The total (final) cost of your care cannot be estimated as it will include the initial visit plus any subsequent visits and reevaluations and will be paid as you go.

The number of visits will vary based on your particular symptoms, goals, and response (or lack of response) to care. ALL care is a “trial of care” meaning that we cannot warrant outcomes and the response (or lack of response) to care will dictate the need for continued care, discontinuation of care or referral.

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