Good Faith Estimate（GFE）通知

If you are uninsured or choose not to use insurance to pay for your care, you generally have the right to receive a Good Faith Estimate of expected charges before scheduled non-emergency services. Sky e-Clinic is a cash-pay telemedicine practice and does not bill insurance directly at launch.

Sky does not create a separate, hand-prepared GFE PDF for every routine appointment. Instead, Sky's scheduling workflow is designed to provide the GFE as one delivery packet at scheduling:

• Selected visit fee shown before booking — The patient sees the exact Sky consultation fee before confirming the appointment.
• Booking confirmation — The confirmation is the patient-specific estimate record. It should show patient name, date of birth, scheduled date/time, selected service, expected Sky charge, provider/practice information, and a link to this Notice.
• Patient Passport notification — The patient receives or can access the confirmation through the approved patient communication workflow.
• This standing Notice — This Notice explains the GFE rights, exclusions, dispute rights, and Sky's fee model in English and Japanese.

If the automated confirmation does not include the required fields, or if a patient asks for a written copy, Sky should provide a written GFE copy through Patient Passport or another approved secure channel. Sky retains the scheduling confirmation, delivery timestamp, and the version of this Notice in effect at the time of service.

• Async / document-only workflow — $50-$80
• Phone, only where permitted and clinically appropriate — $80-$120
• Standard video visit — $100-$150
• Extended video visit — $150-$300
• Standard consultation maximum — $300

The exact selected fee is shown before booking and again in the booking confirmation. The booking confirmation, not the top of the range, is the patient-specific GFE amount for that scheduled service. Fee adjustments within the published $50-$300 standard consultation range are handled by the booking workflow; a fee above $300 or a materially new charge category should be republished and reviewed before use.

The Sky consultation fee does not include medication costs, pharmacy charges, laboratory fees, imaging fees, urgent care, emergency care, specialist care, outside-facility fees, or other outside-provider charges unless specifically listed in the booking confirmation.

A valid payment card is placed on file at booking, but the consultation fee is not charged at booking. After the clinician completes the encounter and required documentation, Sky charges the selected fee disclosed during scheduling. The fee pays for clinical review, evaluation, judgment, documentation, and a clinical decision or visit summary. It is not a prescription fee and does not guarantee a prescription, lab order, note, referral, or specific outcome.

If the selected visit type or expected Sky charge changes before the visit, Sky discloses the changed fee before charging the patient through an updated booking confirmation or a Patient Passport notification documenting the changed fee, the prior fee, and the reason for the change. For changes that emerge during a live/synchronous encounter, such as a chat-to-video escalation or same-encounter added service, the physician may also disclose the change verbally, but Sky will send or record a Patient Passport written confirmation and chart note before the card on file is charged. When applicable law requires a new GFE because the scope, scheduled service, provider, timing, or expected charge changes, Sky provides updated estimate information through the same channel hierarchy. The card on file is not charged until the patient has had a reasonable opportunity to see the updated estimate and Sky has documented agreement.

A Good Faith Estimate is not a contract. It does not require you to receive services from Sky e-Clinic.

If a final bill from a provider or facility is at least $400 more than the Good Faith Estimate from that provider or facility, you may have the right to use the federal Patient-Provider Dispute Resolution process. Sky's standard self-pay consultation range is $50-$300, and the workflow is designed so the exact selected fee disclosed at booking equals the actual Sky consultation charge. More information is available at https://www.cms.gov/nosurprises or 1-800-985-3059.

• Provider — Taichi Imamura, MD
• Practice — SKY E-CLINIC LLC, 1164 Bishop St STE 940, Honolulu, HI 96813
• Phone — (808) 385-8760
• Billing contact — billing@skyeclinic.org
• NPI / TIN — Included in the patient-specific booking confirmation / scheduling-time estimate record before live patient use; public web copies may avoid displaying TIN unless operationally required.

If a visit is converted from chat/asynchronous to video, or if an additional same-encounter service is clinically added, Sky sends or records a Patient Passport written confirmation of the updated fee and documents patient agreement before charging the card on file. In ordinary operation, same-encounter add-on charges are limited by the posted price table and by what can reasonably be evaluated in one encounter. If the patient declines the changed fee before meaningful chart review, risk assessment, evaluation, or other clinical service has occurred, Sky uses the no-charge/full-refund pathway. If meaningful clinician review, risk assessment, documentation, or a clinical decision has already occurred, the fee may be retained under the Payment Policy.