Notice to Patients: Under the No Surprises Act, health care providers are required to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

1. Estimated Scope of Care: This estimate is based on a standard plan of care consisting of an initial evaluation followed by approximately one treatment session per week.

• Initial Evaluation (97161-97163): $175.00 (1 occurrence)

• Follow-up Treatment Sessions: $150.00 per session

• Estimated Frequency: 1 visit per week

• Estimated Total Quantity: 8 to 12 sessions over a 12-month period

2. Estimated Total Cost:

• Minimum Estimated Total: $1,375.00 (Evaluation + 8 sessions)

• Maximum Estimated Total: $1,975.00 (Evaluation + 12 sessions)

3. Patient Rights & Disclaimers:

• Your Right to a GFE: You have the right to receive this Good Faith Estimate for the total expected cost of any non-emergency items or services.

• Not a Contract: This estimate is based on information known at the time of scheduling. It is not a contract and does not obligate you to obtain services from this Practice. Actual charges may vary depending on your clinical progress or the development of new symptoms.

• Right to Dispute: If you receive a bill that is at least $400 more than the maximum estimate ($1,975.00), you can dispute the bill.

• Validity: This Good Faith Estimate is valid for 12 months from the date of issuance.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.