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 physician 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 by plan:

Plan	Monthly Fee	First Visit	Est. Year 1 Total
Standard	$35/mo	$99	~$1,795–$2,027
Essential	$99/mo (all-in)	$99	~$1,287
Complete	$269/mo	$99	~$3,327

Clinical fees only. Prescription medication is billed separately by your chosen pharmacy — most patients pay $0–$30/month for testosterone with insurance. View full pricing details →

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