• We REQUIRE a credit/debit card to hold your scheduled therapy appointments, regardless of billing and even if you are using cash to pay for your sessions.

    We will bill your credit card for:

    • Fees for your therapist if not using insurance
    • Estimated cost shares as indicated by your medical plan (co-pays, coinsurance, deductibles) at time of appointment
    • Remaining balance of cost shares upon receipt of explanation of benefits (if an overpayment was made, a credit will be applied toward future appointments if you are still in treatment or a refund issued if you have discontinued
      therapy)
    • Cancellation fees for missed appointments or less than a 24-hour cancellation of your scheduled appointment,
    • Indirect and secondary services (see Informed Consent for description)
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      Credit Card Details
    • I authorize The Resilience Group to keep my signature and credit card number on file, and to charge my credit card account for the purposes of:

      • Fees for my therapist if not using insurance
      • Estimated cost shares as indicated by my medical plan (co-pays, coinsurance, deductibles) at time of appointment
      • Remaining balance of cost shares upon receipt of explanation of benefits (if an overpayment was made, a credit will be applied toward future
        appointments if I am still in treatment or a refund issued if I have discontinued therapy)
      • Cancellation fees for missed appointments or less than a 24-hour cancellation of my scheduled appointment,
      • Indirect and secondary services (see Informed Consent for description)

      I understand this form is in effect unless I cancel the authorization in writing or three (3) years from date of signature. I will not dispute the charges for reasons outlined above. I further authorize The Resilience Group to disclose my protected health information (PHI) to their credit card processing company and my credit/debit card issuer if I dispute a charge.

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