Good Faith Estimate（医療費見積書）通知

Sky e-Clinic operates on a cash-pay model with a published, transparent fee schedule. Expected consultation charges fall within the following range:

• Async chat consultation: $50 – $80
• Phone consultation: $80 – $120
• Video consultation (Standard): $100 – $150
• Video consultation (Extended): $150 – $200
• Document-only services (sick note, school note, etc.): $50 – $80
• Full Sky e-Clinic fee schedule range: $50 – $400 (current operational maximum: $200; the $400 upper bound is reserved for future fee adjustments and any such adjustment will be republished here before taking effect)

The specific fee for your visit is determined by the consultation type you select, is displayed on the booking page before you confirm, and appears in your booking confirmation. Sky e-Clinic does not bill insurance directly. A superbill is available upon request for out-of-network reimbursement.

For every uninsured / self-pay patient, the two-part Good Faith Estimate is delivered at the time of scheduling: (a) the booking confirmation email and Patient Passport notification supply the patient-specific fields (your name, date of birth, the selected service, the scheduled date and time, and the specific expected charge) and include a direct link to this Notice; and (b) this Notice, available at https://skyeclinic.org/[lang]/gfe-notice, supplies the standing components (fee schedule, charging design, dispute rights, retention, scope). Together, the booking confirmation and this Notice form the Good Faith Estimate required by 45 CFR 149.610. You may also request a copy at any time by contacting Sky e-Clinic at billing@skyeclinic.org or (808) 385-8760.

Sky e-Clinic uses a card-on-file and post-visit charge model. A valid payment card is registered at the time of booking, but the consultation fee is not charged at booking. After the physician completes the encounter and required documentation (including CPT and ICD-10 coding), the consultation fee is charged to the card on file through Elation Patient Payments / Stripe. The amount charged equals the fee disclosed in the booking confirmation — there is no surprise billing. This design structurally prevents the estimate-versus-actual gap that the No Surprises Act exists to remedy.

This Good Faith Estimate is not a contract and does not obligate you to obtain services from Sky e-Clinic. It describes the expected charges for Sky's consultation services based on Sky's published fee schedule. Actual charges may differ if the visit type or service is changed during the encounter (such as an extension from chat to video at the patient's request); however, any such change will be disclosed to you during the encounter before being charged.

Under the federal Patient-Provider Dispute Resolution (PPDR) process, if your final bill is at least $400 more than this Good Faith Estimate for a single provider, you may have the right to dispute the bill. Because Sky e-Clinic's full fee schedule range ($50 – $400) is itself below this $400 threshold, and because the card-on-file + post-visit charge design ensures the charged amount equals the fee disclosed in your booking confirmation, the PPDR threshold cannot be reached under Sky's current fee structure. If Sky's fee schedule changes in the future to bring this threshold into play, this Notice will be updated before any such change takes effect. For more information, visit https://www.cms.gov/nosurprises or call 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 email: billing@skyeclinic.org. Records requests: records@skyeclinic.org. The booking confirmation issued at the time of scheduling lists Sky e-Clinic's National Provider Identifier (NPI), Taxpayer Identification Number (TIN), and the specific date(s) and location of service for the booked visit, together with the patient-specific fields required by 45 CFR 149.610. Patients may also request the NPI and TIN directly at records@skyeclinic.org.

This Good Faith Estimate covers Sky e-Clinic's expected consultation fee for the scheduled visit. Pharmacy charges (the cost of any prescribed medication at the pharmacy), laboratory or imaging charges, urgent care or emergency room charges, and specialist referrals are billed separately by those providers and are not included in Sky's Good Faith Estimate. Sky e-Clinic will display common pharmacy retail-price ranges on the booking page where available, but the final pharmacy price is set by the pharmacy and is not part of this Estimate.

A copy of each patient's booking confirmation and the version of this Notice in effect at the time of the visit is retained by Sky e-Clinic for at least 6 years from the date of service, as required by 45 CFR 149.610(c). Patients may request a copy of their Good Faith Estimate at any time by contacting Sky e-Clinic at billing@skyeclinic.org.