Patients' Rights Notice - Your Cost of Care
This Policy was last changed on August 1, 2026.
Under the federal No Surprises Act, we are required to inform you of the following rights you have regarding advance notice of the out-of-pocket costs you may incur as a self-paying individual.
Frissora Functional Wellness, PLLC, does not participate in any health insurance plans. We are a medical concierge practice, meaning we offer membership-based healthcare where patients pay an upfront annual or monthly fee in exchange for our services. This model allows us to provide you with direct and personalized access and treatment.
Frissora Functional Wellness, PLLC, offers five (5) separate programs and membership options:
• Hormone Wellness Program
• Comprehensive Wellness Program
• Optimal Wellness Program
• Signature Membership
• Premier Membership
All upfront and expected costs for covered services under these agreements are disclosed in writing before you enroll or receive services, including:
• Membership fees (monthly/annual);
• Program or bundle fees (if applicable);
• Any additional per-visit, per-service, or ancillary fees that may apply; and
• Any services that are not included in your membership or program and may be billed separately
If your treatment plan requires any services that are not included in your membership or program and have not been previously identified, you will be informed of expected charges before they are provided, either through:
• A written fee schedule;
• A Good Faith Estimate; or
• An itemized estimate provided at scheduling or upon request.
You have the right to request a Good Faith Estimate of expected charges for scheduled, non-emergency items and services, at any time under the No Surprises Act.
You also have a right to receive a written disclosure of the charges you will be responsible to pay us which will be provided to you via a written Good Faith Estimate of your expected out-of-pocket health care costs within the following time frames:
➢ If you schedule your appointment at least 10 business days in advance: within 3 business days after scheduling.
➢ If you schedule your appointment at least 3 business days in advance: within 1 business day after scheduling.
You also have the right to request a Good Faith Estimate in writing within 3 business days of request. If we are unable to tell you a specific amount (because we cannot predict what specific treatment will be needed), we will disclose to you the estimated maximum amount that you will pay.
You have a right to dispute a bill from our office if it is at least $400 more than the Good Faith Estimate we have provided you. For any questions or more information about your rights under the No Surprises Act, visit www.cms.gov/nosurprises/consumers or call 1- 800-985-3059.
Program and Membership fees do not replace your existing insurance.
By signing your receipt of this notice, you acknowledge that the program and membership services provided by Frissora Functional Wellness, PLLC, will NOT be billed to Medicare and/or to any health insurer. The program and membership services serve as an independent and voluntary health care plan, distinct and separate from any health care benefits made available by your current insurer (if any). You will be financially responsible for paying for all services rendered by other physicians, hospitals, urgent care centers and any laboratory tests and X-ray procedures. If you are a Medicare beneficiary, this is to emphasize that Frissora Functional Wellness, PLLC, does NOT provide any Medicare covered services.
Co-Payments.
Frissora Functional Wellness, PLLC, program and membership fees do not affect co-payments, co-insurance, or deductibles that you are required to pay pursuant to the terms of your insurance coverage outside of Frissora Functional Wellness, PLLC. You will be financially responsible for any co-payments, co-insurance, or deductible amounts required by your insurer for any service completed by a third-party company including but not limited to labs, imaging, prescriptions and specialist visits.
You have the following additional rights under the Massachusetts Patients' First Law:
If you are a Massachusetts resident and receive services from us, you have the following additional rights under the Massachusetts Patients’ First Law.
In the case of providers that participate with your health insurance plan, at the time of scheduling your care, you have a right to request disclosure within 2 days of the out of pocket costs you will be required to pay, including any co-pay or possible deductible Page 2 of 3 amounts, and the provider must assist you, if requested, in seeking additional information about such applicable out-of-pocket costs from your health plan via its consumer toll-free telephone number and website.
If a provider refers you to another provider for further services, prior to making an appointment or you agreeing to use the services of that provider, the provider must give you the opportunity to verify whether the provider participates in your health plan and give you enough information so you can determine what out-of-pocket costs may apply. If a provider directly schedules or otherwise arranges for health care services by another provider on your behalf, prior to scheduling they must verify whether the provider to whom the patient is being referred participates in your health plan; and must notify you if that provider is non-participating in your health plan or if network status cannot be verified.
Frissora Functional Wellness, PLLC is a direct-pay concierge medical practice and does not participate with, bill, or accept any health insurance plans. All services are provided on a self‑pay basis pursuant to our membership agreements and/or program agreements, which disclose all upfront and expected costs for covered services. Because we do not contract with health plans, the portions of the Massachusetts Patients’ First Law that apply to providers who participate with health insurance plans (e.g., plan-specific out-of-pocket estimates based on copayments, coinsurance, or deductibles) may not apply to our practice in the same manner as they would to in-network providers.
If you believe you did not receive adequate advance notice of your out-of-pocket costs under the Massachusetts Patients' First Law, you can find out more about your rights and ability to file complaint at Pricing transparency provisions of an act promoting a resilient health care system that puts patients first (“Patients First”) | Mass.gov.
