Payment Policy and Automated Billing Authorization – Atlantic Counseling & Consultation, Inc.

Payment Policy and Automated Billing Authorization- SECTION 4

We have recently updated our policy and now require all patients to keep an active credit card on file. The credit card will be billed for each appointment to cover your copay, coinsurance and/ or deductible based on your insurance benefits. The credit card will also be billed for any services that are not covered by your insurance company and any missed appointments. If your account should accrue a balance and it is not cleared on or by the 10th of the month, then your card will be billed. The No show/ late cancellation fee ($90) will be billed to your credit card the next business day and a receipt will be emailed to you upon request. For copay, coinsurance, deductible and self- pay payments, a receipt will be emailed upon request.

Name *

First

Last

Email Address *

Date *

Authorization

By signing below, I agree to adhere to the updated policy and I authorize Atlantic Counseling & Consultation to charge my credit card the deductible/copay/coinsurance amount(s) that are determined by my insurance carrier, self- pay amount(s), No show/late cancellation fees and/or sessions already rendered but not covered by insurance. By signing below, I understand that I will call the office with my credit card number and that number will be kept on file until I notify the office.

I have read the statement and authorize my credit card to be used.

Yes No

Cardholder signature *

Are you the cardholder? *

Yes No

If you are not the cardholder, what is your relationship to the cardholder?

Credit card number

Expiration date

If you would prefer to provide your credit card information to us over the phone, please call the office at (781) 335-6000 extension 0. The Administrator is available Monday -Thursday from 8:30am-4pm or you can provide the information to your Clinician at your appointment.