Good Faith Estimate and Self-Pay Agreement

Service Provided: Physical Therapy (PT) visits which may include an evaluation and re-evaluation, manual therapy, exercises, dry needling, self-care activities, neuromuscular re-education, microcurrent treatment, home program, education on diagnosis, and treatment recommendations.

_____ HOPE PT & Wellness is not an in-network provider with my insurance company, I wish
To self-pay for my PT visits
_____ I do not have medical insurance
_____ I have exhausted my insurance coverage and have received a denial for further PT
_____ My treatment is not medically necessary so my insurance will not cover my PT visits
_____ My insurance benefits are currently suspended pending authorization or the outcome of
a hearing or appeal
_____ I am pursuing legal proceedings to cover my medical expenses
_____ I am not a U.S. citizen and I plan to submit to my insurance company on my own

45-minute cash pay visit will cost $90.00 per visit
30-minute cash pay visit will cost $79.00 per visit
15-minute dry needle or manual therapy preventative or tune-up follow-up visit will cost $45.00 per visit and must have a minimum of a 30-minute first visit evaluation performed, at the cost of $79.00.
If you wish to be seen for a new injury or problem, we may require a 45 minute, $85.00, visit to thoroughly evaluate your new problem.

The total cost of your treatment will depend on the type and length of your treatment which will be determined by you and the physical therapist. It is not our policy to wait for a settlement, outcome of a hearing, or insurance appeal to collect payment. Payment is expected at the time of service.

HOPE PT may recommend additional services or items as part of the course of care that will be scheduled separately and is not reflected in this good faith estimate. Separate good faith estimates will be issued upon request if your treatment plan changes.

You have the right to initiate a patient-provider dispute if the billed charges are substantially higher than the charges listed in the good-faith estimate. A dispute initiated by the client will not affect the quality of the physical therapy services received. To initiate a dispute, please email us at, explaining your concern in detail.

Payment Policy: HOPE PT & Wellness believes in cost transparency and your right to shop for high-quality cost-effective services. This is a good faith estimate and is not a contract. You are not obligated to receive physical therapy treatment at HOPE PT.

I understand or agree that payment is expected at each visit to HOPE PT & Wellness for Physical Therapy services rendered.

Customized by Sean Stennett