GFE - DENSO - English Version

Good Faith Estimate for Health Care Services

Tristar Physical Therapy
Date of Good Faith Estimate*

MonthDayYear
Date
This estimate is for Physical/Occupational services through 12/31/2025
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
If under 18, parent/guardian info:
Parent Guardian Full Name
Parent Guardian Date of Birth

MonthDayYear
Date
2. Patient's Service Information

Itemized List of Items and Services Estimated Cost/Visit
Evaluation and all follow-up appointments (cost per visit) $100 per visit
3. Practice / Facility / Provider Information

Practice Legal Name: Tristar Physical Therapy

Practice Tax ID #: 82-2004928 Practice NPI: 1528569316

Contact Person: Jordan Black Phone Number: (423) 317-7772

Practice email address: leadership@tristarpt.com
4. Disclaimers
- The Good Faith Estimate is an estimate and subject to change
- There may be additional items or services not contained in the Good Faith Estimate
- The patient has the right to initiate the patient-provider dispute resolution process
- The Good Faith Estimate is not a contract, and the patient is not bound to the services listed
- This estimate includes a PREpayment discount, money must be collected at time of service
- All payments made are NON-REFUNDABLE
Patient /Guardian Signature

Clear
Relationship
Date

MonthDayYear
Date
Patient / Parent / Guardian Email
example@example.com
Should be Empty: