3416 Association Dr. Appleton WI 54914
1710 and 1716 Lawrence Dr. DePere, WI 54115
1504 S. Commercial St. Neenah, WI 54956
104 Hwy CB Neenah, WI 54956
2417 A Post Rd. Stevens Point, WI 54481
Date of Notice: 1.1.2022
Under the No Surprises Act, health care providers and health care facilities are required to provide a good faith estimate of expected charges for items and services to individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing, upon request or at the time of scheduling health care items and services.
Your diagnosis will not be determined until your assessment. Evolve has the following fee schedule, depending on level of care provided:
Out-Patient Counseling $100.00/hour (not billed separately if in IOP, PHP or RTC)
Registered Dietician $100.00/hour (not billed separately if in IOP, PHP, or RTC)
Intensive Out-Patient (IOP) $300.00/ day, all inclusive*
Partial Hospitalization (PHP) $600.00/day, all inclusive*
Residential Treatment (RTC) $1000.00/day, all inclusive*
*Lab and Pharmacy may be billed separately.
This estimate is valid for 12 months from the date of this notice, as signed below.
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 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 800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 800-985-3059.
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.