Rebecca E. Loerzel, O.D.
Loerzel Eye Care, LLC
Inside Walmart Vision Center
9451 Dunkirk Ln N				1960 Twin Lakes Pkwy
Maple Grove, MN  55311			Roseville, MN  55113
P:  763-416-2312				P:  612-788-1549
F:  763-416-2314				F:  651-633-9761
contact@loerzeleyecare.com
NPI 1396848206

GOOD FAITH ESTIMATE

Comprehensive exam (with refraction) fees range from $90 to $195.  

Medical office visit fees range from $65 - $195.  

Contact lens evaluation fees range from $40 - $80.  

Additional procedures and fees apply when determined to be medically necessary and range from $25 to $99. 

Minnesota Care tax (1.8%) will be added to all services.  

All unpaid balances over 30 days old are subject to late fees and interest.  

If you are billed for $400 more (per provider) than this Good Faith Estimate (GFE), you have the right to dispute the bill.

You may contact Loerzel Eye Care at the contact listed above to let them know the billed charges are at least $400 higher than the GFE. You can ask them to update the bill to match the GFE, ask to negotiate the bill, or ask if there is financial assistance available.  

You may also start a 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 of the date on the original bill.  

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.  

To learn more and get a form to start the process, go to: 
www.cms.gov/nosurprises or call CMS at 1-800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059 .