Dr. Tiffany T. Butler - "The Pain Doctor"
CALL: (240) 264 - 6372
info@drtiffanybutler.com

Good Faith Estimate

"The Pain Doctor" | Baltimore Chiropractor

Transparency in Patient Care

Under federal law, healthcare providers must provide patients who are uninsured (no health insurance), who will not use insurance, and/or who will pay out-of-pocket for healthcare expenses an estimate for healthcare services. 

***You have the right to receive a “Good Faith Estimate” for the expected cost of any non-emergency medical services and/or items upon requeset or when scheduling for such services. This includes related coasts like medical tests, prescription drugs, equipment, and hospital fees.***

***When you schedule an appointment at least five (5) business days in advance, we will provide you with a “Good Faith Estimate” in writing within one (1) business day after scheduling an appointment. In addition, you can ask any physician’s office to give you a “Good Faith Estimate” in writing within three (3) business days after you ask.***

***If you think you are unable to afford a service(s) at our office, you may qualify for financial assistance. Please call us at (240) 264 – 6372 or visit our Payment Options for additional information. We offer payment plans, financial assistance, and disconounts on those who qualify. Don’t let finances prevent you from receiving the healthcare you need and deserve. Everyone has the right to good quality healthcare treatment.***

***If you receive a bill that is at least $400 more than any one provider’s or facility’s “Good Faith Estimate” you can dispute the bill.***

***Be sure to keep a copy of your “Good Faith Estimate” and bill.***

For additional information regarding the No Suprise Act or Good Faith Estimate, please contact us at (240) 264 – 6372 or visit www.cms.gov/nosurprises

Obtain a “Good Faith Estimate”

Complete the form in it’s entirety, if you would like to receive a “Good Faith Estimate” on services and/or products in our office. NOTE: You could be charged more than the estimate if you get additional services, procedures, and/or products during your visit that your doctor did not anticipate.
Our office is ONLY in-network with BlueCross BlueShield (all plans). If you are using any other health insurance, treatment in our office will be considered out-of-network. Please consult with your health insurance plan to determine if you have out-of-network benefits to avoid unnecessary expenses.
Provide a date you would like to receive services at our office.
Prior to receiving any services in our office, the doctor must conduct an examination to determine what procedure(s) and/or product(s) are deemed clinically necessary for your health condition. Once the doctor performs an examination, you will be provided an addition, "Good Faith Estimate" for any recommended treatment procedure(s) and/or product(s) the doctor recommends. The same terms and conditions apply.
By checking "I Agree" you acknowledge that this "Good Faith Estimate", and your actual total cost (patient responsibility) may be different than the amount provided on the "Good Faith Estimate." Information provided is only an estimate and is not a guarantee of final billed charges. Final billed charges may vary from estimates for many reasons, including, but not limited to, the patient's medical condition, unknown circumstances or complications, final diagnosis and recommended treatment prescribed by the provider. Insurance benefit information (where applicable) is based on the information provided by your insurance company as of the date of this estimate. Benefits and eligibility are subject to change and are not a guarantee of payment. The use of and information provided by Harmonious Living Chiropractic: Fitness & Wellness Center "Good Faith Estimate" is confidential. Any attempt to use the "Good Faith Estimate" for any purposes other than those intended by Harmonious Living Chiropractic: Fitness & Wellness Center, as determined by its Clinical Director in its sole discretion, is prohibited.
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