You may obtain a good faith estimate of my (our) charges upon request prior to scheduling

with me (us).

The No Surprises Act is a federal law which provides you with the right to a good faith

estimate of the cost of services at my (our) practice. However, Ohio licensing board rules

require me (us) to provide you with the actual cost of my (our) charges in a written informed

consent form to which you must agree prior to my (our) providing services. That will be

available to you prior to you being seen for services and prior to any billing. In most cases it

is impossible to estimate how many sessions you will need, and that will not be determined

until your concerns are evaluated and will also vary based on the progress that you make,

which depends in part on your efforts with the process. You will be free to discontinue

services at any time or the services may otherwise be terminated in accordance with the

informed consent form language.

Although the No Surprises Law says that you may initiate a dispute process if the actual

charges are substantially in excess of the Good Faith Estimated charges, i.e. if you are

charged $400 more than the estimated cost for a session or for the total estimate provided,

that is unlikely to happen and would be a violation of licensing board rules, since you will be

agreeing up front to actual charges per session prior to being seen. Dispute information is

available upon request, however any changes to my fees will require a change in the

informed consent form fees, which you must agree to prior to having them go into effect,

otherwise the fees will remain in effect for 12 months.

If you would like further clarification, you are welcome to contact us.

Restoration Therapy of Columbus LLC
6209 Riverside Drive, Suite 200A
Dublin, OH 43017

Email: connect@rtcolumbus.com