Good Faith Estimate

OMB Control Number [0938-1433]
Expiration Date [11/2025]

You have the right to receive a “Good Faith Estimate” GFE
explaining how much your medical care will cost
Under the law, health care providers need to give patients who don’t have
insurance or who are not using insurance an estimate of the bill for medical
items and services.

• You have the right to receive a Good Faith Estimate for the total
  expected cost of any non-emergency items or services. This includes
  related costs like medical tests, prescription drugs, equipment, and
  hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate
  in writing at least 1 business day before your medical service or item.
  You can also ask your health care provider, and any other provider you
  choose, for a Good Faith Estimate before you schedule an item or
  service.
• If you receive a bill that is at least $400 more than your Good Faith
  Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.
  For questions or more information about your right to a Good Faith Estimate, visit
  www.cms.gov/nosurprises or call (603) 316-4942.

The next steps in your journey…

• Schedule a Physical Therapy Evaluation either by calling or using the online portal.
• Get a Good Faith Estimate for the evaluation visit.
• After the evaluation your physical Therapist will make a Plan of Care specific to you, your condition, clinical decision making and clinical practice guidelines which is then used to create a second Good Faith Estimate for treatment sessions.
• Throughout your course of treatment work hard and make gains in your recovery.
• Heal your body, reduce pain and increase your quality of life.