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You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.
Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance and estimate of the expected charges for medical services, including psychotherapy services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy.
You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure you have a copy or a picture of your good faith estimate.
For questions or more information about your right to a good faith estimate, visit www.cms.gov/nosurprises/.
Good Faith Estimates for Health Care Items & Services
For ALL HOMESCHOOL EVALUATIONS:
Name: Lighthouse Evaluation Services, PLLCTax Identification Number: 87-4753139Location: Gulf Breeze, Florida - TelehealthService: Annual Homeschool EvaluationCost: $50.00Psychologist: John T. Blaze, Ph.D., FL #PY9366National Provider Identifier (NPI): 1144562695Date of Service: TBD
At Lighthouse Evaluation Services, PLLC, we offer homeschool evaluations for $50.00. Thank you again for choosing Lighthouse Evaluation Services, PLLC for your annual Homeschool Evaluation. We provide this form due to the “No Surprises” Act in 2020 and this is a self-pay evaluation service.
For ALL DIAGNOSTIC EVALUATIONS:
Name: Lighthouse Evaluation Services, PLLCTax Identification Number: 87-4753139Location: Gulf Breeze, Florida - TelehealthService: 90791 Psychiatric Diagnostic Evaluation w/modifier 95 (Telehealth) - This service covers a one-time general clinical evaluation & mental status exam, as well as any symptom checklists & conducted via secure telehealth platform to determine psychological diagnoses (DSM-V; ICD-10) with no treatment recommendations or follow-up services. The evaluation report is included in this charge.Psychologist: John T. Blaze, Ph.D., FL #PY9366National Provider Identifier (NPI): 1144562695Date of Service: TBD
At Lighthouse Evaluation Services, PLLC, we offer Diagnostic Evaluations for $385.00 or $450.00 total. Thank you again for choosing Lighthouse Evaluation Services, PLLC for your Diagnostic Evaluation. We provide this form due to the “No Surprises” Act in 2020 and this is a self-pay evaluation service.
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