Financial Access Review

Request a Financial Access Review

If SacredHLI’s standard self-pay rates present a financial hardship, you may request an individualized review. Tell us what service you are seeking, what you can reasonably afford, and the circumstances you would like us to consider. SacredHLI management will review your request and determine whether a reduced fee, payment arrangement, or another appropriate access pathway may be available. Financial assistance is not guaranteed and depends on individual circumstances and available resources.

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Name *

First

Last

Date of Birth *

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Phone *

Email *

Email

Confirm Email

State of Residence *--- Select Choice ---CaliforniaArizonaColoradoGeorgiaNevadaTexas

Preferred Contact Method *

• Email
• Phone

Consider Financial Birth

Service I Am Seeking *

• Initial Psychiatric Evaluation: Standard Self-Pay $375
• Medication Management Follow-up: Standard Self-Pay $250
• I am not sure which service I need

Do You Currently Have Commercial Health Insurance? *

• Yes
• No
• Unsure

Amount I Can Reasonably Afford for This Visit *

Please enter the amount you believe you can reasonably pay toward this visit.

Type of Financial Assistance Requested *

• Reduced fee
• Payment arrangement
• Temporary financial-hardship consideration
• Help identifying another affordable access pathway
• I am not sure - please help me understand my options

Financial Circumstances You Would Like Us to Consider *

Please briefly explain the financial circumstances affecting your ability to pay the standard self-pay rate. Please do not include detailed medical information, diagnoses, medications, Social Security numbers, banking information, or other unnecessary sensitive information.

Financial Access Review Acknowledgement *

• Yes

I understand that submitting this request does not guarantee a reduced fee, payment arrangement, or other financial assistance. SacredHLI will review my request individually based on my circumstances and available resources.

Custom Captcha *

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Submit Financial Access Request

Please do not submit payment while your Financial Access Review is pending. SacredHLI will contact you with the outcome of the review and the appropriate next step.