PLEASE NOTE:   Pelvic Rehab of Vero complies with the Good Faith Estimate Act for Self-Pay Patients

Good Faith Disclaimer:

The Good Faith Estimate shows the costs of items and services that are reasonably expected for your (uninsured or self-pay individual) healthcare needs for an item or service.  The estimate is based on information known at the time the estimate was created.  The Good Faith Estimate costs are estimates and not the final total charges.

The Good Faith Estimate is not a contract and does not require you to obtain the items and services from any of the providers or facilities identified on the Good Faith 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 the bill.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact your 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.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services.  If you choose the dispute resolution process you must start within 120 calendar days of the date of the original bill.  The patient-provider dispute resolution process may be started if the actual billed charges are $400 more than the expected charges in the Good Faith Estimate.

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, 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 the Department of Health & Human Services at 1-877-696-6775.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-877-696-6775.

Keep a copy of your Good Faith Estimate in a safe place or take a picture of it.