Good Faith Estimate

Good Faith Estimate — 180 Evolution Therapy

Your Rights
as a Patient

Good Faith Estimate & The No Surprises Act

Federal Law — Effective January 1, 2022
This applies to you if you are
Uninsured
No health insurance of any kind
This applies to you if you are
Choosing Not to Use Insurance
You have insurance but prefer to self-pay
This applies to you if you are
Shopping for Care
Comparing costs before scheduling
Under the No Surprises Act, healthcare providers are required by federal law to provide uninsured and self-pay patients with a written Good Faith Estimate of expected costs before services begin. This law ensures you know what to expect financially — with no surprises.
Your Rights Under This Law
1
Right to Receive a Written Estimate

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 such as medical tests, prescription drugs, equipment, and all associated fees.

2
Timing — When You Must Receive It

Your provider must give you a Good Faith Estimate in writing based on the following schedule:

Delivery Timeframes
→
Scheduled 3+ business days in advance: Estimate delivered no later than 1 business day after scheduling.
→
Scheduled 10+ business days in advance: Estimate delivered no later than 3 business days after scheduling.
→
Requested before scheduling: Estimate delivered within 3 business days of your request.
🔁 Note for Recurring Therapy Services

Because therapy is an ongoing service, your Good Faith Estimate will cover up to 12 months of expected sessions — including frequency, session length, and estimated total cost. After 12 months, your provider must issue an updated estimate.

3
Right to Dispute a Higher Bill

If you receive a bill that is $400 or more above your Good Faith Estimate, you have the right to dispute it. Here's how the process works:

Dispute Resolution Process
1
Contact your provider first to resolve the discrepancy directly.
2
If unresolved, submit a dispute application to the U.S. Department of Health and Human Services (HHS).
3
You must initiate the dispute process within 120 days of receiving the excessive bill.
4
Provide your original bill and your Good Faith Estimate. An independent arbitrator will review and make a final determination.
5
Initiating a dispute will not affect the quality of care you receive.
4
Save Your Estimate

Make sure to save a copy or take a photo of your Good Faith Estimate as soon as you receive it. You will need it as documentation if you ever need to initiate the dispute resolution process.

5
Right to Ask for an Estimate at Any Time

You can request a Good Faith Estimate from your provider at any time, even before you schedule a service. You are not required to schedule or commit to services after receiving an estimate.

Questions about your rights?
For full information, visit the official CMS resource page.
Visit cms.gov/nosurprises
This Estimate Is Not a Contract

A Good Faith Estimate does not require you to obtain services from 180 Evolution Therapy or any provider listed in the estimate. Actual charges may differ based on the course of your treatment. If your estimate needs correction before services begin, we will provide an updated estimate as soon as possible — and always before your next appointment.

Our Commitment to Transparency

At 180 Evolution Therapy, we are committed to full compliance with the No Surprises Act. All self-pay and uninsured clients will receive a written Good Faith Estimate prior to beginning services. Our estimate will include session frequency, length, rate per session, and total projected cost for up to 12 months. Questions about your estimate or our fees? Contact our office or call (919) 995-8995 — we're happy to walk you through it.