Medical Disclaimer & Good Faith Estimate Notice
Provider & Facility Information
- Provider: Ana Hopkins, PMHNP-BC
- Facility: Kristin Lulich, Advanced Practice Registered Nursing Inc. / DBA Mind Bloom La Jolla
- Address: 1120 Silverado Street, Suite 203, La Jolla, CA 92037
- TIN: 83-2006063
- Facility NPI: 1659912723
Medical Disclaimer
The information provided on this website and through services rendered by Ana Hopkins, PMHNP-BC is for general informational and therapeutic purposes only. It is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always consult your physician or a qualified healthcare provider with any questions regarding a medical condition. Never disregard professional medical advice or delay seeking it because of information provided here.
Good Faith Estimate (GFE) Notice
In accordance with Section 2799B-7 of the Public Health Service Act and regulations including 45 CFR 149.610(c), 149.610(c)(1), 149.610(c)(1)(iii)(B), 149.610(b)(2), and 149.610(c)(2), uninsured and self-pay patients are entitled to receive a Good Faith Estimate of expected charges.
You have the right to request a Good Faith Estimate:
- Before scheduling a service
- When scheduling a service
- Upon request at any time
Standard Service Fees
| Service Code | Description | Estimated Charge |
|---|---|---|
| 90792 | Psychiatric Diagnostic Evaluation with Medical Services (60 minutes) | $400 |
| 99214 | Evaluation and Management of Established Patient | $200 ($175 for existing patients until Nov 1, 2024) |
Required Disclaimers
- Follow-up Services: After an initial evaluation (90792, 90791, 0591T), continued treatment may require follow-up sessions such as 99214, 90837, or 0592T. A new Good Faith Estimate will be issued upon scheduling each follow-up service.
- Estimates Subject to Change: Charges in the Good Faith Estimate are estimates only and may not reflect the final cost of services rendered.
- Additional Services: Some treatments (e.g., TMS, Spravato) are not included in the initial estimate and may require separate scheduling and estimates.
- Right to Dispute Charges: If your final bill is $400 or more above the Good Faith Estimate, you may initiate the federal patient-provider dispute resolution process.
- Billing Questions: Please contact our billing department with any concerns or disputes. We’re happy to address and correct any errors.
- This Estimate Is Not a Contract: Receiving a Good Faith Estimate does not obligate you to receive services from any provider or facility listed in the estimate.
For questions or to request a Good Faith Estimate, please contact our office directly.