Optimal Therapy Works, PLLC

Dr. Courtney McIntyre, OTD, OTR/L · 6923 NW Friberg Strunk St, Suite 110, Camas, WA 98607

Good Faith Estimate

For an occupational therapy evaluation and a first 12-week course of treatment.

Patient: Sample Child

NPI: 1932682697

Date of birth: MM/DD/YYYY

Tax ID (EIN) 92-1999657

Diagnosis codes: Listed on your estimate

WA OT license 60868661

Evaluation (fixed fee)

Direct assessment

  • Two 60-minute sessions with your child (97165–97167) $480

  • Scoring and written report Interpretation, goals, and plan of careIncluded$240

Evaluation total$720

Treatment

Once a week

Occupational therapy session 60 minutes

  • sensory integrative techniques97533$240 each12 weeks · 12 sessions$2,880

Estimated total, first course of care$3,600

Your rights

  • You’ll get your own written estimate at least 1 business day before your appointment.

  • If your bill is $400 or more above this estimate, you can dispute it within 120 days of the bill date.

  • This estimate is not a contract and doesn’t require you to receive any service. If care continues past 12 weeks, you’ll get an updated estimate.

Learn more at cms.gov/nosurprises or call 1-800-985-3059.

Parent or guardian signature

Date

SAMPLE

Why I don’t bill insurance

My sessions use Ayres Sensory Integration, billed as CPT 97533. Many insurance plans exclude this code or deny it, so families end up with surprise bills months later.

Private pay means you know the full cost on day one.

If you’d like to try for reimbursement, call your plan and ask whether out-of-network 97533 is covered. I provide an itemized receipt for every paid session that you can submit yourself.

HSA and FSA cards are welcome.