Good Faith Estimate
Good Faith Estimate ExplainedYou have the right to receive a Good Faith Estimate of the expected cost of your medical care.
Health care providers are required to give patients who are uninsured or not using insurance an estimate of charges for medical items and services.
You may request a Good Faith Estimate for the total expected cost of any non-emergency services, including related costs such as tests, prescription medications, equipment, and facility fees.
Little Horizons PT and Wellness LLC will provide a written Good Faith Estimate for routine, follow up physical therapy services at your initial evaluation. You may also request a Good Faith Estimate from Little Horizons PT and Wellness LLC before scheduling services.
If your final bill is at least $400 more than your Good Faith Estimate, you have the right to dispute the charge.
Please keep a copy of your Good Faith Estimate. For more information, visit www.cms.gov/nosurprises or call 800-985-3059.
Good Faith Estimate DisclaimerA Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your child’s physical therapy needs. The estimate is based on the information known to us when we do the estimate.
The Good Faith Estimate 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.
If you are billed for $400 more than this Good Faith Estimate (GFE), you have the right to dispute the bill
You may contact the Little Horizons PT and Wellness at info@littlehorizonspt.com to let them know the billed charges are at least $400 higher than the good faith estimate. You can ask us to update the bill to match the GFE, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). 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 GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to:
www.cms.gov/nosurprises or call CMS at 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059 .
Good Faith Estimate for a Physical Therapy Evaluation with Little Horizons PT and Wellness LLCDue to the individualized nature of physical therapy, an estimate of services and total costs may not be available until after the initial evaluation.
However, we can provide a good faith estimate of your evaluation which is as follows:
Pediatric Physical Therapy Evaluation lasting 60-75 minutes: $250.