Good Faith Estimate Notice

SECTION 1 — WHAT IS A GOOD FAITH ESTIMATE

A Good Faith Estimate is a written notice that healthcare providers are required by federal law to give to uninsured patients and patients who are not using health insurance to pay for their care. The Good Faith Estimate shows the expected costs of items and services associated with your care so you can make informed decisions about your healthcare spending before you commit to receiving services.

The No Surprises Act which took effect January 1, 2022 established this right for patients nationwide. Because Spine 33 Rehab PLLC operates exclusively as a cash-pay practice with no direct insurance billing this requirement applies to every patient we serve regardless of whether they have health insurance coverage.

SECTION 2 — WHEN YOU WILL RECEIVE YOUR GOOD FAITH ESTIMATE

You will receive your individualized Good Faith Estimate through your SimplePractice client portal as part of your intake documentation before your first scheduled appointment. Federal law requires that we provide your Good Faith Estimate at least one business day before a scheduled service.

Your Good Faith Estimate will be provided electronically through your patient portal and will require your acknowledgment before your first appointment. If you would prefer to receive your Good Faith Estimate in an alternative format please contact us at info@spine33rehab.com and we will accommodate your request.

SECTION 3 — WHAT YOUR GOOD FAITH ESTIMATE WILL INCLUDE

Your individualized Good Faith Estimate will include all of the following information as required by federal law.

The full legal name, address, phone number, and National Provider Identifier of Spine 33 Rehab PLLC. The Tax Identification Number of Spine 33 Rehab PLLC. A description of each service expected to be provided during your anticipated episode of care. The specific service code associated with each item or service. The expected charge for each individual service listed. The total expected charges for your anticipated plan of care based on information known at the time the estimate is prepared. The date the Good Faith Estimate was prepared. The date of your scheduled first service.

SECTION 4 — OUR CURRENT SERVICE FEES

The following represents our current service fee schedule. Your individualized Good Faith Estimate will reflect the specific services anticipated for your personal care plan and may differ from the general fee schedule below depending on your clinical needs and the services you choose to receive.

Free Discovery Call: 15 minutes | $0

Initial Comprehensive Evaluation: 60 minutes | $175

Follow-Up Virtual Visit: 45 minutes | $99

Follow-Up Visit Package — 5 Sessions: Flexible | $450

Complete Care Plan: Monthly | $449/month

Messaging Subscription: Monthly | $50/month

Fees are subject to change. The fees listed in your individualized Good Faith Estimate at the time of your scheduled service will govern your specific episode of care.

SECTION 5 — HSA AND FSA ELIGIBILITY

Physical therapy services provided by Spine 33 Rehab PLLC are qualified medical expenses under IRS Publication 502. This means you may use Health Savings Account and Flexible Spending Account funds to pay for your care. We accept all major HSA and FSA cards through our secure payment platform. Please verify eligibility with your HSA or FSA administrator before your appointment.

SECTION 6 — IMPORTANT LIMITATIONS OF YOUR GOOD FAITH ESTIMATE

Your Good Faith Estimate is based on information available at the time it is prepared. There are several important limitations you should understand.

Your Good Faith Estimate is not a contract. It does not obligate you to receive all services listed or to pay the full estimated amount. You are always in control of the services you choose to receive.

Your actual charges may differ from your Good Faith Estimate if the services recommended following your comprehensive initial evaluation differ from those anticipated before your evaluation, if you choose to receive additional services not included in your original estimate, if your condition changes significantly during your episode of care requiring a modified plan of care, or if you choose to discontinue care before completing your anticipated plan.

Your Good Faith Estimate does not include charges for services that cannot be reasonably anticipated at the time the estimate is prepared.

Your Good Faith Estimate applies only to services provided by Spine 33 Rehab PLLC. If your provider refers you to another healthcare provider for services outside our scope of practice those providers will be responsible for providing their own separate Good Faith Estimates.

SECTION 7 — YOUR RIGHT TO DISPUTE A BILL

If you receive a bill from Spine 33 Rehab PLLC that is at least $400 more than the total expected charges listed in your Good Faith Estimate you have the right to dispute that bill through the patient-provider dispute resolution process established by the Centers for Medicare and Medicaid Services.

To exercise your right to dispute a bill you must submit a dispute request within 120 calendar days of the date of the bill that exceeds your Good Faith Estimate by $400 or more.

To initiate the dispute resolution process visit cms.gov/nosurprises or contact the No Surprises Help Desk at 1-800-985-3059.

Initiating a billing dispute will not affect the quality of care you receive from Spine 33 Rehab PLLC and we will not retaliate against you in any way for exercising this right.

SECTION 8 — HOW TO REQUEST YOUR GOOD FAITH ESTIMATE

Your Good Faith Estimate will be provided automatically through your SimplePractice client portal before your first appointment. If you have questions about your Good Faith Estimate before booking or would like to request an estimate before scheduling please contact us at the following.

Spine 33 Rehab PLLC

Email: info@spine33rehab.com

Phone: (901) 609-4923

Website: spine33rehab.com

We will provide your Good Faith Estimate within one business day of receiving your request.

SECTION 9 — ADDITIONAL RESOURCES

For more information about your rights under the No Surprises Act including the Good Faith Estimate requirement and the patient-provider dispute resolution process please visit the following federal resources.

Centers for Medicare and Medicaid Services — cms.gov/nosurprises No Surprises Help Desk — 1-800-985-3059 CMS Good Faith Estimate FAQ — cms.gov/nosurprises/consumers