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Good Faith Estimate
Effective January 2022, Congress passed a law basically stating that patients must be fully informed of their costs for any health services prior to receiving the service(s). This is currently only required for patients NOT using their insurance.
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You have been referred to my office for a Psychological Evaluation. I’m required to give you a Good Faith Estimate of the cost if you are uninsured or don’t want to use insurance for this care. The information below is based on my private pay (out of pocket) rates. The cost I am providing is based on the average amount of time I use to complete an evaluation, billed per hour of time.
If you DO intend to use insurance, check with your insurance carrier to find out what your copayment/coinsurance rates and deductible amounts are.
Dr. Spader-Cloud must provide a diagnosis. Because she has not met with the patient, she will use R69 (diagnosis deferred), but this will be modified upon provision of her services.
Dr. Spader-Cloud bills a per hour rate of $180. Most evaluations take 4-7 total hours. Therefore, the total cost for a private pay (non-insurance using) patient can be approximately $720-1260.
The billing CPT codes and their amounts are generally: CPT 90791: 1-1.5 hours, 96130: 2 hours, 96131: 1 hour (only needed occasionally), 96136: 0.5 hours, 96137: 1-3 hours
This is just a rough estimate based on Dr. Spader-Cloud's typical evaluation process. The duration of the evaluation can be longer or shorter depending upon your evaluation needs. Unless required by a court order (an extremely rare situation), you are free to discontinue services at any time, and you are free to discuss any questions you may have. You are ultimately in control of your own healthcare; Dr. Spader-Cloud is here to provide help at your request.
Location of services: 6260 South Sunbury Road, Suite 5, Westerville, Ohio 43081
Identifying information: Name-Michelle Spader-Cloud, PsyD, BCBA-D, National Provider Identifier: 1558794545, Tax ID: 81-1996480
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Signature of Patient or Parent/Legal Guardian (by typing your name below, you indicate your agreement to the information contained within this Private Pay Agreement.
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