Good Faith Estimate

Eleve Physical Therapy LLC · Dr. Ellen Vogt, PT, DPT, OCS

Why you are receiving this

Under the No Surprises Act, effective January 1, 2022, health care practitioners must give a Good Faith Estimate of expected charges to any patient who is uninsured, or who is insured but does not plan to use their insurance benefits to pay for their care. Elevé Physical Therapy is a cash-pay practice and does not bill insurance, so this estimate applies to everyone we treat.

Your provider

No other provider or facility is expected to be involved in your care. If anything is recommended that another provider would deliver, that provider gives you their own separate estimate.

What your care involves

Physical therapy begins with an initial evaluation, followed by treatment visits that may include exercise instruction, neuromuscular re-education, biofeedback instruction, self-care and home management training, and education. The number of visits depends on your symptoms and goals, which we discuss at your evaluation.

Expected charges

Expected diagnosis code(s): To be determined pending full evaluation. Your charges do not depend on the diagnosis — the rates above are the same whatever we find. Once your evaluation is complete, you receive an updated estimate showing the diagnosis codes and the number of visits expected.

Estimated total cost

The Good Faith Estimate works to show the cost of items and services that are reasonably expected for your physical therapy needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment.

You are entitled to receive this “Good Faith Estimate” of what the charges could be for physical therapy services provided to you. While it is not possible for a physical therapist to know, in advance, how many physical therapy sessions may be necessary or appropriate for a given person upon the initiation of physical therapy, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of physical therapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider listed, nor does it include any services rendered to you that are not identified here.

Most clients will attend one physical therapy visit per week, but the frequency of physical therapy visits that are appropriate in your case may be more or less than once per week, depending upon your individual needs and preference. It is also important, when determining your total estimate, to take into consideration vacations, holidays, emergencies, and sick time.

You may project any potential future cost(s) by multiplying the session fee of $100 by the total number of sessions, in addition to the initial evaluation fee of $150. This will result in your total estimated cost for physical therapy service(s).

For example, an initial evaluation and four follow-up treatments would cost:

$150 initial evaluation + ($100 per follow-up session × 4 sessions) = $550

If you attend therapy for a longer period, your total estimated charges will increase according to the number of visits and length of treatment.

We are providing you with this Good Faith Estimate based on the information the clinician has available at this time, and actual items, services, or charges may differ from this Good Faith Estimate as treatment progresses. The fees above are current as of the date of this estimate and apply to telehealth services.

Total estimated charges — one session per week

Total estimated charges — two sessions per week

Dr. Ellen Vogt recognizes every client’s physical therapy journey is unique. How long you need to engage in physical therapy and how often you attend sessions will be influenced by many factors, including:

• Your schedule and life circumstances
• Physical therapist availability
• Ongoing life challenges
• The nature of your specific impairments and how you address them
• Personal finances and resources

You and your physical therapist will continually assess the appropriate frequency of physical therapy and will work together to determine when you have met your goals and are ready for discharge, and / or a new Good Faith Estimate will be issued should the frequency of sessions or needs change. As related, you may request a new Good Faith Estimate at any time in writing during your treatment.

Your rights

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).

You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan or the information provided to you in this Good Faith Estimate. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

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.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

Questions before your visit? Email ellen@eleve-pt.com or call (502) 208-6499.