Please give us a call at (406) 777-1048 schedule an appointment today!

Active Care Wellness Center believes in the value of chiropractic care for you and your family toward the goal of achieving total health and wellness. Our chiropractic office participates in most insurance programs, but please call us at (406) 777-1048 if you have any questions about whether you can use your insurance to pay for your chiropractic care. For patients who have little or no chiropractic insurance coverage, we offer a cash discount when the balance is paid in full after each office visit.  To learn more about our payment options for chiropractic and wellness care, you can call our Stevensville chiropractic office directly at (406) 777-1048 and one of our friendly staff will be happy to answer all your questions.

No Insurance:

Our goal at Active Care Wellness Center is to allow everyone to experience the benefits of chiropractic care and adjustments.  For patients who have little or no chiropractic insurance coverage, we can offer a  cash discount.  Many patients choose to pay directly for their visits with the chiropractor, especially as they discover that chiropractic care is actually extremely cost-effective and affordable.  For these patients, chiropractic care is often cheaper and more effective than alternative pain treatments such as pain medications or invasive surgery.

Insurance

Most insurance plans are accepted at our chiropractic office.  Before you start a chiropractic care plan, our staff would be happy to verify your benefits and explain them to you at no charge.

 

Good Faith Estimate

(For use by nonparticipating providers and nonparticipating emergency facilities beginning January 1, 2022)

 Instructions

 The Department of Health and Human Services (HHS) developed standard notice and consent documents under section 2799B-2(d) of the Public Health Service Act (PHS Act). These documents are for use when providing items and services to participants, beneficiaries, enrollees, or covered individuals in group health plans or group or individual health insurance coverage, including Federal Employees Health Benefits (FEHB) plans by either:

• A nonparticipating provider or nonparticipating emergency facility when furnishing certain post-stabilization services, or

• A nonparticipating provider (or facility on behalf of the provider) when furnishing nonemergency services (other than ancillary services) at certain participating health care facilities.

These documents provide the form and manner of the notice and consent documents specified by the Secretary of HHS under 45 CFR 149.410 and 149.420. HHS considers use of these documents in accordance with these instructions to be good faith compliance with the notice and consent requirements of section 2799B-2(d) of the PHS Act, provided that all other requirements are met. To the extent a state develops notice and consent documents that meet the statutory and regulatory requirements under section 2799B-2(d) of the PHS Act and 45 CFR 149.410 and 149.420, the state-developed documents will meet the Secretary’s specifications regarding the form and manner of the notice and consent documents.

These documents may not be modified by providers or facilities, except as indicated in brackets or as may be necessary to reflect applicable state law. To use these documents properly, the nonparticipating provider or facility must fill in any blanks that appear in brackets with the appropriate information. Providers and facilities must fill out the notice and consent documents completely and delete the bracketed italicized text before presenting the documents to patients.

In particular, providers and facilities must fill in the blanks in the “Estimate of what you may pay” section and the “More details about your estimate” section before presenting the documents to patients.

The standard notice and consent documents must be given physically separate from and not attached to or incorporated into any other documents. The documents must not be hidden or included among other forms, and a representative of the provider or facility must be physically present or available by phone to explain the documents and estimates to the individual, and answer any questions, as necessary. The documents must meet applicable language access requirements, as specified in 45 CFR 149.420. The provider or facility is responsible for translating these documents or providing a qualified interpreter, as applicable, when necessary to meet those requirements. The standard notice must be provided on paper, or, when feasible, electronically, if selected by the individual. The individual must be provided with a copy of the signed consent document in-person, by mail or via email, as selected by the individual.

If an individual makes an appointment for the relevant items or services at least 72 hours before the date that the items and services are to be furnished, these notice and consent documents must be provided to the individual, or the individual’s authorized representative, at least 72 hours before the date that the items and services are to be furnished. If the individual makes an appointment for the relevant items or services within 72 hours of the date the items and services are to be furnished, these notice and consent documents must be provided to the individual, or the individual’s authorized representative, on the day the appointment is scheduled. In a situation where an individual is provided the notice and consent documents on the day the items or services are to be furnished, including for post-stabilization services, the documents must be provided no later than 3 hours prior to furnishing the relevant items or services.

NOTE: The information provided in these instructions is intended to be only a general informal summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance upon which it is based. Refer to the applicable statutes, regulations, and other interpretive materials for complete and current information.

Do not include these instructions with the standard notice and consent documents given to patients.

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-1401. The time required to complete this information collection is estimated to average 1.3 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26- 05, Baltimore, Maryland 21244-1850.



Surprise Billing Protection Form

 

The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.

IMPORTANT: You aren’t required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider when you received care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less. If you’d like assistance with this document, ask your provider or a patient advocate. Take a picture and/or keep a copy of this form for your records.

 

You’re getting this notice because this provider or facility isn’t in your health plan’s network. This means the provider or facility doesn’t have an agreement with your plan.

Getting care from this provider or facility could cost you more.

 

If your plan covers the item or service you’re getting, federal law protects you from higher bills:

• When you get emergency care from out-of-network providers and facilities, or

• When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.

Ask your health care provider or patient advocate if you need help knowing if these protections apply to you.

If you sign this form, you may pay more because:

• You are giving up your protections under the law.

• You may owe the full costs billed for items and services received.

• Your health plan might not count any of the amount you pay towards your deductible and out of-pocket limit. Contact your health plan for more information.

You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change.

Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this provider or facility, or another one.

See the next page for your cost estimate.

 

Estimate of what you could pay

Total cost estimate of what you may be asked to pay: Chiropractic Day 1 $180.00 -$220.00, Repeat Chiropractic visit $55.00 - $80.00, Physical Therapy Day 1 $120.00-$200.00, Repeat Physical Therapy $148.00-$180.00

Review your detailed estimate. See Page 4 for a cost estimate for each item or service you’ll get.

Call your health plan. Your plan may have better information about how much you will be asked to pay. You also can ask about what’s covered under your plan and your provider options.

Questions about this notice and estimate? Call Active Care Wellness Center 406.777.1048

 ►Questions about your rights? Contact www.cms.gov or your insurance company

Understanding your options

You can also get the items or services described in this notice from these providers who are in-network with your health plan:

More information about your rights and protections

Visit www.cms.gov/nosurprises/consum... for more information about your rights under federal law.

 By signing, I give up my federal consumer protections and agree to pay more for out-of-network care.

 With my signature, I am saying that I agree to get the items or services from (select all that apply):

☐ Active Care Wellness Center ☐ Dr. Amy Berglund ☐ Dr. Beth Dominicis ☐ Dr. Brittney Martin

With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I also understand that:

• I’m giving up some consumer billing protections under federal law.

• I may get a bill for the full charges for these items and services, or have to pay out-of-network cost-sharing under my health plan.

• I was given a written notice on ____________ explaining that my provider or facility isn’t in my health plan’s network, the estimated cost of services, and what I may owe if I agree to be treated by this provider or facility.

• I got the notice either on paper or electronically, consistent with my choice.

• I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit.

• I can end this agreement by notifying the provider or facility in writing before getting services. IMPORTANT: You don’t have to sign this form. But if you don’t sign, this provider or facility might not treat you. You can choose to get care from a provider or facility in your health plan’s network. _______________________________________ or _________________________________________ Patient’s signature                                                         Guardian/authorized representative’s signature _______________________________________      _________________________________________

Print name of patient                                                     Print name of guardian/authorized representative _______________________________________      _________________________________________

Date and time of signature                                            Date and time of signature

Take a picture and/or keep a copy of this form.

It contains important information about your rights and protections.

 


 

More details about your estimate

Patient name: _________________________________________________________________________

Out-of-network provider(s)or facility name: Active Care Wellness Center

The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover.  This means that the final cost of services may be different than this estimate.

Contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay.

Chiropractic

Service Code

Description

Estimated amount to be billed

 

 

99203

Exam

$140.00

 

 

98941

 

Chiropractic Spinal Manipulation

$55.00

 

 

97140

Manual Therapy

$40.00

 

 

97112

Neuromuscular Education

$44.00

 

 

97012

Mechanical Traction

$20.00

 

 

97110

Therapeutic Exercise

$38.00

 

 

 

Typical Chiropractic new patient appointment cost: $195.00-$230.00

 

 

 

 

Typical follow-up Chiropractic cost: $55.00-$85.00

 

 

Physical Therapy

Service Code

Description

Estimated amount to be billed

 

 

97162

Exam

$142.00

 

 

97140

 

Manual Therapy

$40.00

 

 

97112

Neuromuscular Education

$44.00

 

 

97110

Therapeutic Exercise

$38.00

 

 

 

Typical Physical Therapy new patient appointment cost: $150.00-$250.00

 

 

 

 

Typical follow-up Physical Therapy cost: $148.00-$190.00

 

 

Location

Office Hours

Our Regular Schedule

Monday

8 AM

6 PM

Tuesday

7 AM

6 PM

Wednesday

8 AM

6 PM

Thursday

7 AM

6 PM

Friday

varies by week

Saturday

Closed

Closed

Sunday

Closed

Closed

Monday
8 AM 6 PM
Tuesday
7 AM 6 PM
Wednesday
8 AM 6 PM
Thursday
7 AM 6 PM
Friday
varies by week
Saturday
Closed Closed
Sunday
Closed Closed