Sacred Olive Counseling, PLLC
We are required by law to provide you with this information. This document describes your protections against unexpected medical bills. It is for those whose insurance we do not accept or for those who choose to pay out-of-pocket. It also asks if you'd like to give up your insurance benefits and protections and pay more for out-of-network care.
IMPORTANT: You aren't required to sign this form and shouldn't sign it if you didn't have a choice of health care provider before scheduling care. You can choose to get care from a provider or facility in your health plan's network, which may cost you less. If you'd like assistance with this document, ask your provider. Take a picture and/or keep a copy of this form for your records.
You're getting this notice because this provider or facility isn't in your health plan's network and is considered out-of-network. This means the provider or facility doesn't have an agreement with your plan to provide services. Getting care from this provider or facility will likely cost you more. If your plan covers the item or service you're getting, federal law protects you from higher bills when:
Ask your health care provider or patient advocate if you're not sure if these protections apply to you. If you sign this form, be aware that you may pay more because:
Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn't one, you can also ask your health plan if they can work out an agreement with this provider or facility (or another one) to lower your costs.
Fees to be expected for each session/service. Please be aware that fees are not always charged on the day of the session due to unexpected circumstances. Please keep your own tally of what is owed and be prepared for the amounts owed to remain in your account until charged.
These fees are as follows — Independently Licensed Professional Counselors (LPCs):
| Service | Fee |
|---|---|
| Intake session (50 minutes) | $165 |
| Regular session (50 minutes) | $150 |
Total fee if a client chose to see an LPC counselor weekly for 52 weeks (one year): $165 intake session, plus $150 × 51 weekly sessions = $7,815.
Every client's needs are different: some clients see a counselor less often, some for a shorter length of time, some more. Your needs are individual, and you are part of that decision.
Sacred Olive Counseling, PLLC · 9983 Mineral Wells Highway, Weatherford TX 76088 · (469) 759‑0730
The Good Faith Estimate law asks providers to diagnose clients before they are seen. However, until we have met with you, it is commonly not seen as ethical to give a diagnosis, and so we are providing some options below. As the list of actual possible diagnosis options is quite expansive, we would also like to provide the link to the Diagnostic and Statistical Manual of Mental Disorders (DSM‑5) for your review: dsm.psychiatryonline.org.
Commonly used diagnosis codes:
If you have any questions about a diagnosis, please speak with your counselor.