Good Faith Estimate Notice

Under the federal No Surprises Act (effective January 1, 2022), you have the right to receive a Good Faith Estimate (GFE) explaining the expected cost of any non-emergency items or services from healthcare providers, including pediatric occupational, physical, and speech therapy services offered through ViaThera. This right applies to anyone who is uninsured or who is insured but chooses not to use their insurance to pay for services (which includes all ViaThera families, because ViaThera is private-pay only).

• The therapist or therapy practice providing the service.
• A description of the primary item or service (evaluation, ongoing treatment, telehealth session, etc.).
• The expected charges for each item or service, including ViaThera's platform fee.
• Diagnosis codes, service codes, and the expected frequency where applicable.
• A disclaimer that actual charges may differ from the estimate.

• You may request a Good Faith Estimate before scheduling any service.
• Once you schedule a service at least 3 business days in advance, we will provide a written GFE no later than 1 business day after scheduling.
• If you schedule at least 10 business days in advance, we will provide the GFE no later than 3 business days after scheduling.
• The estimate covers the primary item/service and reasonably-expected related items from the same provider for the next 12 months.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you may dispute the bill through the federal Patient-Provider Dispute Resolution process. You must start the dispute process within 120 calendar days 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 the estimate. If the agency disagrees and agrees with the provider, you will have to pay the higher amount. Learn more at cms.gov/nosurprises or call 1-800-985-3059.