Good Faith Estimate

Synergy Wellness Good Faith Estimate & Disclosure Form 

If you do not have health insurance or choose not to bill your health insurance; or, your health benefit plan may or may not provide coverage for all the health care services you are scheduled to receive; or, our practice does not participate with your insurance:

Your health benefit plan may or may not reimburse a provider for all services provided if the provider is not in your health benefit plan network. You may be responsible for the costs of the services that are not covered by your health benefit plan.                                      

A nonparticipating provider must provide good faith estimates of the cost of the health care services to be provided. A good-faith estimate does not take into account unforeseen circumstances, which may affect the cost of the health care services provided.

You also have a right to request that the health care services be performed by a provider who participates with your health benefit plan network. You also may contact your carrier to arrange for those services to be provided at what may be a lower cost and to receive information on in-network providers who can perform the health care services that you need.

Estimated Services and Items                                                    

Primary Service	Diagnosis Code (ICD-10 Code)	Service Code (CPT, HCPCS, DRG)	Quantity	Non- insurance Cost
New Patient Examination	One per patient	98943	One per patient	$85-$120
Re-Examination	Varies by patient	99212	Quantity varies by patients’ needs	$50-$85
Spinal Manipulation	Varies by patient	98941	Quantity varies by patients’ needs	$50
Extra Spinal Adjustment	Varies by patient	98943	Quantity varies by patients’ needs	$40
Manual Therapy Techniques	Varies by patient	97140	Quantity varies by patients’ needs	$30

Disclaimers:

There may be additional items or services that we recommend as part of the course of care that must be scheduled or requested separately and are not reflected in this good faith estimate.

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. Actual items, services, or charges may differ from the good faith estimate. 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.

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, and your bill is $400 or more than your Good Faith Estimate, federal law allows you to dispute the bill.

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

You can contact us, let us know the billed charges are higher than the Good Faith Estimate, and ask us 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 (approximately four months) of the date on the original bill.

If you dispute your bill, we cannot move the bill for the disputed item or service into collection or threaten to do so, or if the bill has already moved into collection, we are required to cease collection efforts. We must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded. We also cannot take or threaten to take any retributive action against you for disputing your bill. There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate, reduced by the $25 fee. If the SDR entity disagrees with you and agrees with us, you will have to pay the higher amount.

The initiation of the dispute resolution process will not adversely affect the quality of health care services furnished to you by our practice.

This good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the good faith estimate.

Dr. Laura Vanloon D.C.     

1775 E. 14 Mile Ste. 101     

Birmingham, MI 48009   

(248)408-8183