Patient Right: Estimate of Cost of Services
SRPT will provide all patients who do not have insurance or who are not using insurance an estimate of the bill for therapy services. Please retain a copy of your "Good Faith Estimate" (GFE) quote.
- Our initial estimate will be for the cost of the first visit, which will be for the evaluation. This estimate will be provided to you at least one (1) business day prior to the evaluation or prior to scheduling if you prefer.
- Before commencing with a treatment, a second estimate will be provided to you based on the established Plan of Care. If your Plan of Care needs modification during the episode of care because of your therapy needs, a new condition, or per your request, you will be informed and provided with a new estimate, and you will have the option to continue or cease treatments.
- If you receive a bill that is $400 or more than the "Good Faith Estimate," you can dispute the bill utilizing the Patient-Provider Dispute Resolution Process. The dispute resolution entities (SDR) are certified and selected by Health & Human Services (HHS). You must submit a dispute notice, the provider's bill, and the "Good Faith Estimate" to HHS within 120 days of receiving the final bill from our practice. HHS will collect a $25 fee with your dispute resolution application.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call SRPT at (254) 965-2040.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may 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 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.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call (800) 985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 985-3059.