Good Faith Estimate — Revive Low T Clinic

Federal Law — Effective January 1, 2022

You have the right to receive a written
"Good Faith Estimate"
of expected charges before you receive care.

Under the No Surprises Act · 45 CFR §149.610 · Consolidated Appropriations Act of 2021

Who This Right Applies To

This right applies to you if any of the following is true:

You do not have health insurance of any kind — including commercial, employer-sponsored, or government insurance.
You have insurance but are not using it for this service — you are choosing to pay out-of-pocket directly to Revive (self-pay).
You are shopping for care and want to know the expected cost before scheduling.

Note for Revive patients: Because Revive Low T Clinic is a cash-pay practice for clinical services, every patient at Revive is effectively a self-pay patient for office visits, labs, and consultations — regardless of insurance status. This means every Revive patient has the right to a Good Faith Estimate.

What Your Good Faith Estimate Includes

Your written estimate will contain:

Itemised service list

A line-by-line breakdown of every service expected at your visit — office visits, lab panels, injections, and more.

Expected charge per service

The actual dollar amount you are expected to be billed for each item, including any applicable discounts.

Diagnosis & service codes

ICD-10 diagnosis codes and CPT procedure codes for each listed item — the same codes used for billing.

Provider information

The name, National Provider Identifier (NPI), Tax ID (TIN), and location of the clinician providing your care.

12-month recurring estimate

For ongoing treatment, your estimate covers all reasonably expected charges for a full 12-month period of care.

Your dispute rights

Required notice of your right to dispute a bill if actual charges exceed the estimate by $400 or more.

When You Will Receive Your Estimate

Federal law requires estimates to be delivered within specific timeframes after scheduling or requesting:

Situation	Estimate Delivered Within
Service scheduled 3–9 business days in advance	1 business day after scheduling
Service scheduled 10+ business days in advance	3 business days after scheduling
You request an estimate without scheduling	3 business days after your request
Your protocol changes materially after an estimate is issued	Updated estimate provided as soon as practicable

How Revive Issues Your Estimate

Revive uses a two-phase approach so you always have a complete, accurate estimate before any charges are incurred:

Phase 1 — At Scheduling

Before your first visit

When you book your first appointment, we issue a Pre-First-Visit GFE covering the $99 first visit — the only cost knowable before your doctor assessment.

Delivered by email or in-person at time of booking. Diagnosis listed as R69 (deferred, pending evaluation) — the standard code before a clinical assessment.

Phase 2 — At First Visit

Before you leave your first appointment

Once your clinician has assessed you and determined your treatment plan, we issue a 12-Month Recurring GFE covering your full expected Year 1 course of care.

This covers every subsequent scheduled visit within 12 months — no new estimate needed before each follow-up.

Keep your estimate. You will need a copy to initiate a billing dispute if your actual charges exceed the estimate by $400 or more. Revive will provide you a copy by email and file a copy in your medical record.

Your Right to Dispute a Bill

If your bill is $400 or more above your Good Faith Estimate

You have the right to dispute the bill within 120 calendar days of receiving it. To initiate a dispute, you must have a copy of your Good Faith Estimate. The dispute resolution process is administered by an independent third party selected by the U.S. Department of Health & Human Services.

Starting a dispute will not affect the quality of care you receive at Revive Low T Clinic. Your estimate is not a contract and does not require you to receive services from Revive.

To initiate a dispute or learn more: CMS No Surprises Help Desk — 1-800-985-3059 or visit www.cms.gov/medical-bill-rights

Revive's Transparent Pricing

Revive publishes its complete fee schedule publicly. Typical expected charges for the TRT membership:

Item	Fee	When
Membership	$35/mo membership, or $175 every 6 months prepaid; checkups are extra ($329)	Monthly, or every 6 months prepaid
First visit	$99	Once, at the start
Checkup visit	$329 (doctor visit $297 and blood draw $32)	Every 6 months
Recommended visits	$227 each (doctor visit $195 and blood draw $32)	Months 3 and 9 of Year 1
Labs	Our discounted price (about $40) for the tests, or billed to your insurance by the lab	With each checkup and each recommended visit

Clinical fees only. Prescription medication is billed separately by your chosen pharmacy. Most patients pay $0–30/mo for TRT meds, with insurance or without. View full pricing details →

Download Patient Forms

These forms are Word documents (.docx). You may complete them before your visit to save time at check-in. We go over the financial policy and the TRT and weight-loss consent forms with you at your visit.

Your Good Faith Estimate is given to you in writing when you schedule, or any time you ask. It uses the fees in the table above. See current pricing →

Patient Intake & Consent Forms

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New Patient Intake Form

Registration, medical history, and symptom questionnaire.

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AI-Assisted Care Consent

Disclosure and consent for AI-assisted charting and clinical support.

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Informed Consent — ED Treatment

Consent for erectile dysfunction treatment options.

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Informed Consent — Peptide Therapy

Consent for peptide treatment protocols.

This notice is issued pursuant to the No Surprises Act, Title I of Division BB of the Consolidated Appropriations Act of 2021 (Pub. L. 116-260), and its implementing regulations at 45 CFR §149.610. This notice does not constitute a Good Faith Estimate — written estimates are provided separately at time of scheduling or upon request. For questions contact Revive Low T Clinic at (206) 960-4770 or revivelowt.com.

Your Right to a
Good Faith Estimate