Authorization to save Credit Cards on file 

You will be asked for a credit card at the time you check in and the information will be held securely in our billing system. You will always have the option to pay fees using another payment method if you do so in a timely manner. Charges to the credit card will be determined as follows: 
 
Copays/Self Pay Charges – Copays are due on the date of service, per your contract with your insurance company. Self-pay charges are due on the date of service, per your agreement with our office. You may present another method of payment prior to, or at the time of service. If another method of payment is not offered by the date of service, your credit card will be charged. 

Psychological Testing/Phone Sessions – These are some examples of services that may or may not be covered by your insurance. For this reason, we will require a credit card on file if you are scheduled for any of these treatments or incur any of these fees. 

Late Cancellation or No-Show Charges – These charges are generated by your provider if you fail to show up for a scheduled appointment, or if you do not give adequate notice (24 hours) for canceling an appointment. If you incur such a charge, you can pay it at the time of cancelation, or we can charge your card.  
 
This will not compromise your ability to dispute a charge or question your insurance company’s determination of payment. 

PLEASE NOTE: If the Credit Card provided expires, becomes invalid, or lacks sufficient funds, it will be required that you update your Credit Card on File information and/or pay your balance in full in order to reschedule with your provider.