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.