Good Faith Estimate
Good Faith Estimate
As of January 1st, 2022, law requires healthcare professionals to provide a Good Faith Estimate to clients who are not utilizing insurance benefits. This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate is estimated based on cost per session x 50 weeks in a year, which is a gross overestimate of a yearly cost of services.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. (i.e. court fees) You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
Provider information:
Practice name: Solaire Therapy & Wellness, PLLC
Provider name & credentials: Lori Streator, LMHC, LCPC
NPI number: 1487088662
Contact: 941-400-3079
Office address(es): 9030 58th Dr E, Bradenton, FL 34202
Service description: Initial evaluation
Service code: 90791
Cost per service: $165
Service description: Individual therapy (60 min)
Service code: 90837
Cost per service: $150
Service description: Individual therapy (45 min)
Service code: 90834
Cost per service: $112.50
Estimated total cost for one year (Individual therapy):
Example based on weekly sessions: (e.g., $150 x 52 = $7,800)
Example based on bi-weekly sessions: (e.g., $150 x 26 = $3,900)
Example based on monthly sessions (e.g., $150 x 12 = $1,800)
Actual number of sessions may vary depending on treatment needs.
Additional fees (if applicable)
Letter/report writing: $150/hour
Returned check fee: $25/check
Court/legal fees: $400/hr with a 6 hour minimum (see Practice Policies for details on court fees when requested by a judge)
No Show/Late Cancellation Fee: $50/no-show or late cancellation
Please refer to our Practice Policies for a complete list of fees and services. Fees are subject to change with 30 days’ written notice.
Disclaimer
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, 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 (about 4 months) 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 Good Faith Estimate. 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 HHS at (800) 368-1019. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
I acknowledge I have received this Good Faith Estimate from my provider, have reviewed the information, and have the opportunity to print a copy for my files if I choose to do so.
This GFE is not a contract and does not obligate you to receive the services listed.
If you have any questions or comments about this legal document as outlined above, you can contact us at:
Solaire Therapy & Wellness, PLLC
9030 58th Dr. E, Suite 101A
Bradenton, FL 34202
United States