Good Faith Estimate
Bjerke Nutrition and Wellness, LLC
125 Landmark Dr NE, Suite 2 Owatonna, MN 55060 P: 507-774-0699 F: 888-490-2036 firstname.lastname@example.org
Practice information: NPI: 1467061291 EIN: 85-2016595
HEALTHCARE ITEMS AND SERVICES UNDER THE NO SURPRISES ACT
As of January 1, 2022, all healthcare providers are required to provide estimates for the costs of your care. You are entitled to receive a copy of your Good Faith Estimate (GFE) when you schedule an appointment, and/or upon request. The GFE shows the cost of items and services that are reasonably expected for your healthcare needs and treatment. This protects you from balance billing and other unexpected charges. Bjerke Nutrition and Wellness, LLC provides you with a GFE upon scheduling and/or upon your request. This Good Faith Estimate does not include unexpected costs that could arise during treatment. Unexpected costs may include fees for outside referrals, cancellation and/or no-show fees, fees for lab work we request, etc. The GFE supplied by our office covers the providers at Bjerke Nutrition and Wellness, LLC.
HOW DOES THIS AFFECT BILLING AND PAYMENT POLICIES AT BJERKE NUTRITION AND WELLNESS?
The law protects you from surprise billing and “unexpected surprise charges”. Bjerke Nutrition and Wellness, LLC does not send patients a bill. You will pay for your sessions either 1) prior to the first session to serve as a confirmation or 2) charge the day of your session (policies and financial responsibility forms).
WHAT IS THE ESTIMATE? DO I OWE THIS AMOUNT?
Under provisions of this law, we are required to provide you with an estimate of your healthcare costs. You are entitled to receive this “Good Faith Estimate” of what the charges could be for nutrition and psychotherapy services provided to you. While it is not possible for a dietitian to know, in advance, how many sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of nutrition therapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.
Bjerke Nutrition and Wellness, LLC provides nutrition services from licensed dietitians. Our provider is listed below with their corresponding National Provider Identifier (NPI) and state licensure. The practice NPI and tax identification number (EIN) is listed at the top of the page.
Providers at Bjerke Nutrition and Wellness, LLC with their corresponding NPI and licensure information are listed below.
Tracy Bjerke, RDN, LDN NPI: 1780022202 License 3202
LOCATION OF SERVICES
Bjerke Nutrition and Wellness, LLC is located at 125 Landmark Dr NE, Suite 2, Owatonna, MN 55060. The providers listed conduct both in-person (upon request) and virtual sessions. The estimate does not change based on your session being at the office or via telehealth.
EXPECTED FREQUENCY AND LENGTH OF TREATMENT
We recognize that each patient has a unique treatment journey. Factors affecting your length of treatment may include: your presenting problem, history of presenting problem, stated goals for treatment, challenges and life circumstances, availability to schedule sessions, your support system, age at problem onset, presence of commonly occurring conditions we see in our patients, and others. Our standard practice is to create a treatment plan with patient input after the initial session (or we have time to develop treatment goals) and revise/update the treatment plan after six months. Therefore, we are providing this estimate based on the timeframe we use for treatment planning.
The Good Faith Estimate is not a contract and therefore does not obligate you to receive the services listed below. Bjerke Nutrition and Wellness, LLC believes the therapeutic relationship to be paramount. We regard your autonomy, right to self-determination, and choice to receive treatment where you will most benefit.
If you are billed more than the GFE you may appeal the bill. You may read more about this process in the GFE. If you are billed more than the GFE by our office or any provider, federal law allows you to dispute (appeal) the bill. You may start the dispute resolution process with the U.S. Department of Health and Human Services (HHS). HHS will charge patients $25 to initiate the dispute process. If you choose the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date of the original bill. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS directly at 1-800-985-3059. Additionally, you may contact us at 507-774-0699 or email the practice owner, Tracy at email@example.com.
**Note that you should not receive a bill from Bjerke Nutrition and Wellness, LLC. Please refer to the payment policies and financial responsibilities. As you pay for each session as it occurs, we are not in the practice of sending out patient billing statements.
Please keep a copy of your GFE for your records. Let us know if you have any questions.