Good Faith Estimate
Provider Information
Internal Medicine Wellbeing PLLC
EIN: 92-3575436
Dr. Aleksey Etinger
Individual NPI: 1225304496
New York License # 280493
Dr. Yuriy Dekhkanov
Individual NPI: 1235405432
New York License # 280435
Location of Services: Mobile Location and/or Clinic Location
You are entitled to receive a “Good Faith Estimate” for your medical and nursing services from Internal Medicine Wellbeing PLLC (“Internal Medicine Wellbeing”). While it is not possible to know in advance how many treatments may be needed or provided to each client, we have provided this estimate based on what the charges could be for your medical services as of the date above.
This Good Faith Estimate is not intended to serve as a recommendation for treatment or a requirement that you need to schedule or attend any number of treatments. The number of recommended treatments will depend on what you and Internal Medicine Wellbeing believe is appropriate based on your individual circumstances. The total cost of services may depend on your needs, the volume of treatments you receive, and whether you request additional treatments. You may choose to discontinue your medical services at any time.
Please let Internal Medicine Wellbeing know if you have questions about your treatment plan, payment options, or the information provided in this Good Faith Estimate.
Estimate Details
The following is a detailed list of expected charges for services scheduled by you or us on your behalf.
Estimate Details for medical and nursing services:
Service Diagnosis Code Quantity Expected cost
Clinic IV Drip E86.0 1 $129 to $199
Mobile IV Drip E86.0 1 $229 to $299
Add-on E63.9 1 $29 to $99 each
Weight Loss Programs E66.9 1 $99 to $899 per month
Medicine Concierge/consults Z00.01 1 $299 to $499 per visit or month
Description of Services: See our website: http://www.imwellbeing.com
Date of Commencement of Service(s): as scheduled by you.
Disclaimers
This Good Faith Estimate is not a contract. It does not oblige you to receive any services from Internal Medicine Wellbeing.
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your needs. The estimate is based on information known at the time the estimate was created.
There may be additional services that are recommended as part of your course of care that must be scheduled or requested separately. Such services are not reflected in this Good Faith Estimate. Separate Good Faith Estimates will be issued upon scheduling or upon request of the items or services listed here:
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. Actual items, services, and charges may differ from this Good Faith Estimate. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If the actual amount charged to you substantially exceeds the costs listed in this Good Faith Estimate, you have the right to dispute the bill. You may contact Internal Medicine Wellbeing if the billed charges are higher than the Good Faith Estimate. You can ask us to update the bill to match the Good Faith Estimate, negotiate the bill, or ask if there is financial assistance available.
You may also use the dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about four months) of the date on the original bill. There is a $25 fee to use the dispute process. Initiating the dispute resolution process will not adversely affect the quality of the APRN services provided by Internal Medicine Wellbeing.
If the agency reviewing your dispute agrees with you, you will have to pay the estimated total for services provided on this Good Faith Estimate. If HHS disagrees with you and agrees with Internal Medicine Wellbeing, you will be obligated to pay the higher amount on your bill. To learn more and get a form to start the process, go to http://www.cms.gov/nosurprises or call HHS at 1-800-985-3059.
Keep a copy of this Good Faith Estimate in a safe place or take a picture of it. You will need it if you choose to initiate the dispute resolution process outlined above.