Good Faith Estimates

As of January 1, 2022, all healthcare providers are required to provide estimates for the costs of your care. The Good Faith Estimate shows the cost of items and services that are reasonably expected for your healthcare needs and treatment. This will be provided upon request. This Good Faith Estimate does not include unexpected costs that could arise during treatment.

Under provisions of this law, we are required to provide you with an estimate of your healthcare costs. You are entitled to receive this “Good Faith Estimate” of what the charges could be for nutrition services provided to you. While it is not possible for a dietitian to know, in advance, how many sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of nutrition sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of sessions with your dietitian. The number of visits that are appropriate in your case, and the estimated cost for those services will ultimately depend on your needs and what you agree to in consultation with your dietitian. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. We ultimately value the importance of self-determination and the therapeutic relationship. It is important that you understand your right to choose your provider based on your unique needs, the provider's specialization, and the right fit.

We recognize that each patient has a unique treatment journey. Factors affecting your length of treatment may include: your presenting problem, history of presenting problem, stated goals for treatment, challenges and life circumstances, availability to schedule sessions, your support system, age at problem onset, presence of commonly occurring conditions we see in our patients, and others. Our standard practice is to create a treatment plan with patient input after the initial session (or we have time to develop treatment goals) and revise/update the treatment plan after six months. Therefore, we are providing this estimate based on the timeframe we use for treatment planning.

The Good Faith Estimate is not a contract and therefore does not obligate you to receive the services listed below. We regard your autonomy, right to self-determination, and choice to receive treatment where you will most benefit.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care 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 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 more than this Good Faith Estimate, you have the right to dispute the bill.

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. 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 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.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 803-569-9164.For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 803- 569-9164.