top of page

Good Faith Estimate

Good Faith Estimate Notice

Thank you for choosing Keystone Pediatric Therapy! Are you seeking services as a private payer? A private payer is someone who has chosen not to use insurance to help pay for medical or therapeutic services. But instead, will pay out of pocket.


Please review this next section to learn more about your rights as a private payer.


According to the No Surprise Act, you have the right to receive a Good Faith Estimate that explains how much your medical services will cost. Under this law, ALL health care providers must provide the total expected cost and charges to ALL of their patients who are not using insurance for medical services (private payers).


This is a federal law and all providers (not just Keystone Pediatric Therapy) must comply. You are entitled to, and must receive your Good Faith Estimate before your scheduled service.


If you receive a bill from a provider who gave you a Good Faith Estimate that is $400 more than the original estimate, you can dispute the bill. During your treatment with Keystone Pediatric Therapy, your provider may recommend additional services as part of your treatment that are not reflected in the original Good Faith Estimate. Your provider should get your consent that you indeed do understand, that any additional services/costs are in addition to the original Good Faith Estimate. If you are charged more than your Good Faith Estimate and you would like to dispute it, contact the U.S. Department of Health and Human Services (HHS). You must start the dispute process within 120 calendar days of the date of the original bill in dispute. Please note that the HHS may charge you a fee to initiate the dispute process.


A copy of your Good Faith Estimate can be located in your secure client portal.


Should you have any further questions or just want additional information about the Surprise Act or the Good Faith Estimate, feel free to go to or call HHS at (800) 985-3059.



Aireal Ishola, OTR/L, Owner

8595 Beechmont Ave., Suite 202

Cincinnati, Ohio 45255

(513) 278-7006

bottom of page