Good Faith Estimate
The services provided by the Friends Counseling Center, Inc. (FCC) are performed by master’s level counselors and/or who are licensed by the State of Indiana. A standard session time is 53 minutes.
INSURANCE: If you have insurance that includes Mental Health Benefits, the initial intake session, and/or yearly evaluation will be billed at $200 and each session thereafter will be billed at $150. You will be responsible for the remaining amount not covered under your Mental Health Benefits. The insurance benefits quoted by your insurance company and/or FCC are not a guarantee of payment. Please note that benefits can change periodically and may affect the amount that your insurance company will pay. The final confirmation of your benefits and copay will appear on the Explanation of Benefits you receive from the insurance company.
SLIDING FEE: Uninsured clients, those who do not have insurance or choose not to bill services through insurance may be offered a sliding scale fee based on the client's annual household income. An additional $20 will be billed for the initial session and yearly intake.
Proof of income must be provided to determine and set the session fee (i.e. a current tax return or the three most recent pay stubs). Clients should report any changes to income and provide supporting documentation. Clients must provide their proof of income via mail, email, fax, or in person before or at their first appointment. If proof of income is not received by the first appointment, clients will be charged $80 for the initial session. Clients will not be able to reschedule until proof of income is provided.
Annual Household Income Fee:
Under $20,000 $60 $50,001-60,000 $95
$20,001-25,000 $65 $60,001-70,000 $100
$25,001-30,000 $70 $70,001-80,000 $110
$30,001-35,000 $75 $80,001-90,000
$35,001-40,000 $80 $120 $90,001-100,000 $130
$40,001-50,000 $85 Over $100,000 $150
PAYMENT: Payment for counseling is due at the time of your counseling session. No cash will be accepted at satellite sites. Checks should be made payable to Friends Counseling Center (FCC). We accept Visa, MasterCard, and Discover. If you miss two payments, we will not be able to reschedule you until we receive your full payment or a payment plan has been arranged with our financial department. Checks returned for non-sufficient funds are charged $25.
SESSIONS and CANCELLATIONS: It is very important to let us know at least 24 hours in advance if an unexpected conflict arises with your appointment time. If you have three late cancellations or no-shows, within 3 months you may be terminated as a client. You may be charged a fee of $30 for late cancellations. You may be charged the full fee for no-shows if you have insurance. Missed appointments cannot be filed with insurance. In emergencies, i.e. unexpected weather, you will not be charged.
FEE FOR RECORDS: Clients will be required to fill out a medical request form. The fee for receiving a copy of their records will not exceed $20 per set of records. Per Indiana law, the maximum fees for copying medical records are:
Sub-Ed: The fee for the 8-hour sub-ed class is $150. The Fee for the 12-hour Sub Ed Class is $175.00. This is a self-paid class, insurance is not utilized for this service as it is an educational group.
Court: The charge is $175/hr port to port with a minimum of one hour. After one hour, it is billed in 30-minute increments. A $350 retainer fee is required.
Report Writing: When a report is requested the client will be billed $75.
Intern Fees: The rate for services provided by an intern is $30 for a standard session that lasts 53 minutes. Please note that insurance and Medicaid cannot be used for intern services. If you wish to use insurance or Medicaid, you will need to schedule an appointment with a licensed clinician.
The services provided by the Friends Counseling Center, Inc. (FCC) are performed by master’s level counselors and/or who are licensed by the State of Indiana. A standard session time is 53 minutes.
INSURANCE: If you have insurance that includes Mental Health Benefits, the initial intake session, and/or yearly evaluation will be billed at $200 and each session thereafter will be billed at $150. You will be responsible for the remaining amount not covered under your Mental Health Benefits. The insurance benefits quoted by your insurance company and/or FCC are not a guarantee of payment. Please note that benefits can change periodically and may affect the amount that your insurance company will pay. The final confirmation of your benefits and copay will appear on the Explanation of Benefits you receive from the insurance company.
SLIDING FEE: Uninsured clients, those who do not have insurance or choose not to bill services through insurance may be offered a sliding scale fee based on the client's annual household income. An additional $20 will be billed for the initial session and yearly intake.
Proof of income must be provided to determine and set the session fee (i.e. a current tax return or the three most recent pay stubs). Clients should report any changes to income and provide supporting documentation. Clients must provide their proof of income via mail, email, fax, or in person before or at their first appointment. If proof of income is not received by the first appointment, clients will be charged $80 for the initial session. Clients will not be able to reschedule until proof of income is provided.
Annual Household Income Fee:
Under $20,000 $60 $50,001-60,000 $95
$20,001-25,000 $65 $60,001-70,000 $100
$25,001-30,000 $70 $70,001-80,000 $110
$30,001-35,000 $75 $80,001-90,000
$35,001-40,000 $80 $120 $90,001-100,000 $130
$40,001-50,000 $85 Over $100,000 $150
PAYMENT: Payment for counseling is due at the time of your counseling session. No cash will be accepted at satellite sites. Checks should be made payable to Friends Counseling Center (FCC). We accept Visa, MasterCard, and Discover. If you miss two payments, we will not be able to reschedule you until we receive your full payment or a payment plan has been arranged with our financial department. Checks returned for non-sufficient funds are charged $25.
SESSIONS and CANCELLATIONS: It is very important to let us know at least 24 hours in advance if an unexpected conflict arises with your appointment time. If you have three late cancellations or no-shows, within 3 months you may be terminated as a client. You may be charged a fee of $30 for late cancellations. You may be charged the full fee for no-shows if you have insurance. Missed appointments cannot be filed with insurance. In emergencies, i.e. unexpected weather, you will not be charged.
FEE FOR RECORDS: Clients will be required to fill out a medical request form. The fee for receiving a copy of their records will not exceed $20 per set of records. Per Indiana law, the maximum fees for copying medical records are:
- First 10 pages: $1 per page
- Pages 11–50: 50¢ per page
- Pages 51 and higher: 25¢ per page
- Expedited processing fee: $10 if the records are needed within two working days
- Certified records: $20
Sub-Ed: The fee for the 8-hour sub-ed class is $150. The Fee for the 12-hour Sub Ed Class is $175.00. This is a self-paid class, insurance is not utilized for this service as it is an educational group.
Court: The charge is $175/hr port to port with a minimum of one hour. After one hour, it is billed in 30-minute increments. A $350 retainer fee is required.
Report Writing: When a report is requested the client will be billed $75.
Intern Fees: The rate for services provided by an intern is $30 for a standard session that lasts 53 minutes. Please note that insurance and Medicaid cannot be used for intern services. If you wish to use insurance or Medicaid, you will need to schedule an appointment with a licensed clinician.
3565 S. State Road 13, Wabash, IN 46992 | 260.563.8453 | 260.569.0335 FAX
[email protected] | www.friendscounseling.org
Wabash | Logansport | Marion | North Manchester | Tipton
[email protected] | www.friendscounseling.org
Wabash | Logansport | Marion | North Manchester | Tipton