Good Faith Estimate

Patient Right: Estimate of Cost of Services

As of January 1, 2022 under the No Surprise act we must provide a Good Faith Estimate of expected charges upon request. This law pertains to patients who do not have insurance or are not using insurance (Cash pay).

Clear Lake Physical Therapy & Rehab Specialists will provide all patients who do not have insurance or who are not using insurance an estimate of the bill for therapy services. Please retain a copy of your “Good Faith Estimate” (GFE) quote.

Our rate for services is:

• Evaluation (visit 1) – $180.00
• Our visit rate is $60.00 per 15 minutes and our typical visit is 45 minutes totaling $120.00 for each additional visit. (The actual duration of each visit will be determined by you and your therapist).

This Good faith estimate shows the cost of our services that are reasonably expected for your healthcare needs. This estimate will not include any unknown or unexpected costs that may arise during your care. If your Plan of Care needs modification during the episode of care because of your therapy needs, a new condition, or per your request, you will be informed and provided with a new estimate, and you will have the option to continue or cease treatments.

If you receive a bill that is $400 or more than the “Good Faith Estimate,” you can dispute the bill utilizing the Patient-Provider Dispute Resolution Process. The dispute resolution entities are certified and selected by Health & Human Services. You must submit a dispute notice, the provider’s bill, and the “Good Faith Estimate” to HHS within 120 days of receiving the final bill from our practice. HHS will collect a $25 fee with your dispute resolution application.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call Clear Lake Physical Therapy & Rehab Specialists at 715-986-4103.

• BCMS Form
• BOM 247 GFE Notice 1-10-22