Dear Park Avenue Chiropractic patient(s),

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You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost Under the law, healthcare providers need to give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items and services.

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• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

• Make sure your healthcare provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

• Make sure to save a copy or picture of your Good Faith Estimate.

 

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

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It is difficult to determine the true length of treatment for your health and/or conditions, 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 by 5-10%. When we make changes to our fees, we will let you know and provide you with an updated Good Faith Estimate.
 

Provider Facility

Park Avenue Chiropractic

18 Park Ave. Mount Airy, MD 20872

 

Provider Information

Dr. Jiwoon Ryu, License #S03776, NPI #1114344900

 

Expected Services Related to Diagnoses

This Good Faith Estimate explains your providers’ rates 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 by 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

Initial Appointment (Evaluation and Treatment): $120

Subsequent Appointments (as needed) $60

If you attend the initial visit ($120) and five follow-up visits, twice per week, (60x5=$300), your estimated fees are $420.

If you attend treatment weekly, your estimated fees for one month (4 weeks) would be $240.

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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 actual items, services, or charges may differ from the Good Faith Estimate.