Good Faith Estimate

Effective Date: September 16, 2026

Notice of Right to Receive a Good Faith Estimate

Under the No Surprises Act, patients who are uninsured or who choose not to use insurance have the right to receive a Good Faith Estimate explaining the expected cost of healthcare items and services before receiving care. Healthcare providers are required to provide this estimate to uninsured or self-pay patients when care is scheduled or when an estimate is requested.

Your Right to an Estimate

You have the right to receive a Good Faith Estimate for the total expected cost of non-emergency physical therapy and rehabilitation services provided by Revolution Rehab.

This may include, when applicable:

Initial physical therapy evaluations and consultations

Re-evaluations and progress tracking visits

Follow-up physical therapy treatment sessions

Dry needling or specialized manual therapy techniques

Customized exercise instruction and rehabilitation programs

Other recommended physical therapy or wellness services discussed with you

When You May Receive a Good Faith Estimate

You may receive a Good Faith Estimate if:

You do not have health insurance

You have health insurance but choose not to submit claims through insurance (self-pay/cash-based care)

You request an estimate before scheduling care

You schedule a physical therapy service at our office

A Good Faith Estimate will be provided in writing, either on paper or electronically, depending on your preferred delivery method. Electronic estimates will be provided in a format that you can save and print.

Estimates Are Not a Final Bill

A Good Faith Estimate is not a contract and does not require you to receive services from Revolution Rehab. It is an estimate based on the clinical information available at the time it is generated.

The actual total cost of care may vary depending on:

Initial physical examination findings and clinical recommendations

Whether specialized interventions or additional sessions are recommended

Your plan of care and overall treatment goals

The total number of therapy visits you choose to receive

Changes in your physical condition, functional progress, or treatment preferences

If Your Bill Is Higher Than Expected

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right under federal law to dispute the bill through the federal patient-provider dispute resolution process.

We encourage you to contact our office directly if you have any questions, concerns, or discrepancies regarding your estimate or charges.

Keep a Copy

We recommend that you save or print a copy of your Good Faith Estimate for your personal records.

Questions or Estimate Requests

To request a Good Faith Estimate or ask questions regarding expected self-pay costs or superbills, please contact us:

Revolution Rehab

Dr. Tyler Kinch, PT, DPT

4981 Plainfield Ave NE

Grand Rapids, MI 49525

Phone: (616) 344-4469