Good Faith Estimate For Patients not using Insurance

Restore Pelvic Health Physical Therapy

1314 Westgate Pkwy Suite 7

Dothan, AL 36303

Phone: (334) 268-5880

Fax: (334) 268-5865

Email: Kelli@restoreptwiregrass.com

Purpose

This Good Faith Estimate is intended to provide you with an estimate of the charges you'll incur at Restore Pelvic Health Physical Therapy. Uninsured and self-pay clients, even if seeking reimbursement from their insurance company, are entitled to Good Faith Estimates as of January 1st, 2022, under the No Surprises Act.

Clinic Fee Structure

Your physical therapy treatment will include an initial evaluation and a combination of treatments that may include manual therapy, exercise, neuromuscular retraining, and more. The total cost of your care will include the initial visit, plus any follow-up visits, and will be paid as you go. Your first session will be an evaluation (along with any treatment provided). Follow-up visits are based on a plan determined at your initial evaluation. The number of visits will vary based on your particular symptoms and goals, which we will discuss during your evaluation. At your request, you can be provided with a superbill for each session that you can submit to your insurance company for reimbursement. We cannot guarantee reimbursement from your insurance company, and you are responsible for seeking reimbursement from your insurance company.

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 or items 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). If at any point during your care, you wish to dispute or have questions about a charge, we request that you contact us first so that we may attempt to resolve the matter.

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 $35 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.

EstimatedTotal Cost: (all prices include dry needling and most other modalities, when appropriate)

Evaluation (50-60 minutes):  $150.00

Follow ups 50-60 minutes: (recommended): $135.00 or 30 minutes $75.00

Additional Costs: Shockwave (see next page)

PACKAGES: Can include ANY treatments performed during that 30 min (except shockwave)

30 min

3 sessions $195 (65 ea)

4 sessions $ 252 (63 ea)

6 sessions $ 360 (60 ea)

1 Hour

3 sessions $375 (125 ea)

4 sessions $ 492 (123 ea)

6 sessions $ 720 ($120 ea)

Shockwave (ESWT)

Erectile Dysfunction (ED) Treatments

PACKAGES:  No per session rate until after 6 sessions

6 initial sessions:    $1,200  (200 ea)

After 6 initial sessions:

$185 per session OR  (3 additional sessions) $525 (175 ea)

Maintenance visits: $99

Peripheral Neuropathy: Includes shockwave, EMTT, & LLLT

PACKAGES: No per session rate until after 6 sessions

6 initial sessions: $840    (140 ea)

After 6 initial sessions:

$135 per session OR 6 additional sessions $ 780 (130 ea)

Maintenance visits: $75

Other conditions (anything besides ED & peripheral neuropathy)

Tendinopathies, pain, carpal tunnel, incontinence, pelvic pain, dyspareunia, whiplash, tennis or golfers elbow, TMD, etc

Trial Session $99 (allowed 1 time per lifetime)

Per session $130

PACKAGES: Includes shockwave (ESWT), EMTT,  LLLT

3 initial sessions $375 (125 ea)

6 initial sessions   $720 ($120 ea)

After 6 initial sessions: 

$115 per session OR 3 additional $330 (110 ea)

Maintenance  $89

*Pricing subject to change