Your Right to a Good Faith Estimate

Effective: January 1, 2022. Last reviewed: May 27, 2026.

Under the federal No Surprises Act, you have the right to receive a Good Faith Estimate of what your care at Georgia Spine and Sports Rehab will cost before you receive it. This page explains that right, what the estimate includes, and how to ask for one.

What the Estimate Includes

A Good Faith Estimate from Georgia Spine and Sports Rehab is provided in writing and includes:

• The expected charges for the items or services you have scheduled or requested.
• A diagnosis code, service code, and description of each item or service we expect to provide.
• The provider's name (Dr. Joseph Krzemien, D.C. or Dr. Corie Terwilliger, D.C., as applicable).
• Our contact information.
• The date the estimate was prepared.

The estimate covers what we, as your treating clinic, expect to charge. It does not include charges from other providers you may be referred to for imaging, advanced testing, or additional care. If we refer you, we will let you know so you can request an estimate from that provider as well.

Who Is Entitled to a Good Faith Estimate

You are entitled to a Good Faith Estimate from us if any of the following apply:

• You do not have health insurance.
• You have health insurance but you choose not to use it to pay for your care with us.
• You request an estimate, in advance, for items or services we may provide.

When You Will Receive Your Estimate

If you schedule an item or service at least three business days in advance, you will receive your Good Faith Estimate in writing no later than one business day after scheduling. If you schedule at least ten business days in advance, you will receive it no later than three business days after scheduling.

If you ask for an estimate without scheduling, you will receive a written Good Faith Estimate within three business days of your request.

Your Right to Dispute the Bill

If you receive a bill from us that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill through a federal Patient-Provider Dispute Resolution process.

1. You must start the dispute process within 120 calendar days of receiving the bill in question.
2. 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 the Good Faith Estimate. If the agency disagrees and sides with the provider, you will have to pay the higher amount.
3. Visit cms.gov/nosurprises or call 1-800-985-3059 for more information about your right to a Good Faith Estimate and to start a dispute.

Keep Your Estimate

Make sure to save a copy or picture of your Good Faith Estimate. You will need it if you dispute a final bill.

How This Fits With Our Cash-Pay Pricing

Georgia Spine and Sports Rehab is a cash-pay clinic. We publish typical service prices on our pricing page so you can budget before you book. When you schedule, we will confirm the specific services you are receiving and issue a written Good Faith Estimate. If your treatment plan changes during care, we will provide an updated estimate before the change.

If You Want to Submit Your Visit to Insurance

If you have insurance and plan to submit your visit for out-of-network reimbursement, we will provide you with an itemized superbill. The Good Faith Estimate rules apply to patients who do not use insurance. If you are using insurance, contact your health plan for an Advance Explanation of Benefits.

For More Information

To learn more about your rights under the No Surprises Act, visit cms.gov/nosurprises or call the federal help line at 1-800-985-3059.

This notice is provided pursuant to the No Surprises Act of 2020 and the federal implementing rules at 45 CFR 149.610. Last reviewed: May 27, 2026.