Good Faith Estimate for Healthcare Services at Couve Chiropractic – January 2023
Dear Couve Chiropractic patient(s),
A new law has been passed called The No Surprise Act. The purpose of this law is to protect patients from unexpected medical bills. As healthcare providers, we are required to provide you with a Good Faith Estimate of anticipated costs for your health and/or mental health care. It is difficult to determine the true length of treatment for your health and/or mental health care, and each patient has a right to decide how long they would like treatment. Below you will find a fee schedule for the services typically offered by our providers, and we will collaborate with you on a regular basis to determine how many sessions and what services you may need. The Good Faith Estimate below is valid for 12 months. These fees are subject to change. Our fees increase yearly 5-10%. When we make changes to our fees, we will let you know and provide you with an updated Good Faith Estimate. Please take a moment to review and sign the following form. Thank you for your patronage and if you have any questions, please don’t hesitate to ask.
Provider Facility
Couve Chiropractic, 12420 NW 36th Ave, Vancouver, WA 98685
Phone: 360.450.1331
Rendering Providers at Couve Chiropractic
Dr. Nicole Valio Snow, DC- License #60916864, NPI #1184188351
Dr. Andrew Marino, DC - License #601092201, NPI #1013511492
Shawnda Wills, LMT - License #MA61446737, NPI: 1225521818
Expected Services Related to Diagnoses
This Good Faith Estimate explains your providers’ rate for each service provided. Your provider will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your diagnosis and presenting clinical concerns. The number of total sessions and/or services in the treatment is based on the patient’s needs, preferences, and progress made in treatment.
Diagnosis
To be determined by your provider.
Good Faith Estimate for Healthcare Items and Services
This Good Faith Estimate below explains your providers rate for each service provided. Please note that the expected cost is based on the fee for service, multiplied by the number of services needed (as determined in collaboration with your provider). The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. The estimated costs are valid for 12 months from the date of the Good Faith Estimate. Our fees increase yearly 5-10%. When we make changes to our fees, we will let you know and provide you with an updated Good Faith Estimate.
Services & Pricing
New Patient Visit + Chiropractic Adjustment + Soft tissue work, up to 60 minutes - $200
Chiropractic Adjustment, up to 15 minutes - $65
Chiropractic Adjustment + Soft tissue work (cupping, gua sha, massage therapy, etc.), up to 30 minutes - $85
Massage therapy, up to 30 minutes - $50
Massage therapy, up to 60 minutes - $100
Massage therapy, up to 90 minutes - $150
Abdominal massage/ gynovisceral work (including Mercier Therapy/ Maya Abdominal Massage), up to 1 hour - $150
Disclaimers
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 is not a contract and does not require you to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate. There may be additional items or services the provider or facility recommends as part of the course of your care that must be scheduled or requested separately and are not reflected in the good faith estimate. The information provided in the Good Faith Estimate is only an estimate regarding items or services reasonably expected to be furnished at the time the Good Faith Estimate is issued and that actual items, services, or charges may differ from the Good Faith Estimate.
Your Rights
If, as a cash-paying patient, 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. 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. 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.. Initiating such a process will not adversely affect the quality of services rendered. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or (800) 368-1019. Please keep a copy of this Good Faith Estimate or take pictures of it for your records.