Request for Written Good Faith Estimate

Request for Written Good Faith Estimate*

Laura McKaig Physical Therapy LLC
You have requested a written Good Faith Estimate (GFE) about our physical therapy costs. Please be aware that, in compliance with Part II of No Surprises Billing Act*, we are now required to obtain Protected Health Information from you for this GFE, such as:

--Date of Birth

--Medical Diagnosis

--Your email and/or mailing address

We are also required to send this written document to you through email or through the Postal Service.

A verbal Good Faith Estimate is also available and does not require giving us this information.

You can also request a written copy of the GFE upon scheduling your initial evaluation.

Disclaimer: this provider is not in agreement with the legal requirements of obtaining this information from you if you are just requesting cost estimates.

*Surprise Billing and Transparency Requirements, Subpart G - Protection of Uninsured or Self-Pay Individuals, Effective Date January 1, 2022
Do you wish to proceed with a written Good Faith Estimate?

No, I would prefer to receive a verbal estimate at this time.Yes, I wish to proceed with a written estimate. I will provide accurate information concerning my date of birth, mailing address, and my medical diagnosis, if known.
Name

First NameLast Name
Email
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Phone Number
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Request for Written Good Faith Estimate*