Good Faith Estimate

Restore Pelvic Health Physical Therapy

1347 W Main Street

Dothan, AL 36301

Phone: (334) 268-5880

Fax: (334) 268-5865

Email: jessica@restorepelvichealthpt.net

GOOD FAITH ESTIMATE

This Good Faith Estimate is intended to provide you with an estimate of the charges you'll incur at Restore Pelvic Health Physical Therapy, LLC. 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: Jessica Munk, PT, DPT; NPI 1487251823

Clinic Fee Structure:

Your physical therapy treatment will include an initial evaluation and a combination of treatments that may include manual therapy, exercise, and neuromuscular retraining. 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 $185, and follow-up visits are $185 each. The number of follow-up visits varies based on your plan of care, which is determined at your initial evaluation. You have the right to agree to the number of recommended visits or limit the number as you need. I provide you with a bill following your session that you can submit to your insurance company for reimbursement. I cannot guarantee reimbursement from your insurance company. 

Estimated Total Cost:

Initial Appointment (Evaluation): $185

Subsequent Appointments (as needed): $185/hour. Discounts will be discussed and agreed upon at evaluation. 

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.