Good Faith Estimate
Restore Pelvic Health Physical Therapy
1314 Westgate Pkwy Suite 7
Dothan, AL 36303
Phone: (334) 268-5880
Fax: (334) 268-5865
Email: Kelli@restorepelvichealthpt.net
Good Faith Estimate
Purpose
This Good Faith Estimate is intended to provide you with an estimate of the charges you'll incur at Restore 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.
Providers Involved in Your Care
Kelli Daniels, PT, DPT; NPI 1306261656
Makayla Palmer, PT, DPT NPI 1356938047
TIffany Nolin, PT, DPT NPI:1407822778
Isabella Hildreth, PT, DPT NPI: 1124904750
Susan Walthaus, PT, MS NPI: 1457690869
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. If you have any questions about your upcoming appointment, please don't hesitate to reach out before your visit. 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, which costs $175. Follow-up visits are based on a plan determined at your initial evaluation. Each subsequent one-hour session will be $150. 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.
Estimated Total Cost
Evaluation: (this would include dry needling with no extra charge if appropriate)
$175 for 50-60 minutes
Follow- up treatments: (this would include dry needling with no extra charge if appropriate)
$150 for 50-60 minutes, $75 for 30 minutes
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 $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.