I hereby acknowledge that I am personally liable for all fees for services performed on my behalf by PeoplePsych LLC (“PeoplePsych” These fees includes full session charges for those without insurance; charges passed on to the client from the insurance company including deductible and co-pay charges; and all unreimbursed insurance claims.
While PeoplePsych will submit claims on my behalf to health insurance companies where possible, I am fully liable for such charges that are not paid in a timely manner by the insurance company. I irrevocably agree that any bill that remains unpaid 30 days after submission may, at PeoplePsych’s sole option, be charged to my credit card.
I hereby authorize the credit card company listed below to recognize and approve charges against the credit card listed below as submitted by PeoplePsych. I certify that the below listed card is issued to me, and/or that I am an authorized signatory on the account; and that said card is currently valid. I further agree to maintain and keep on file with PeoplePsych a valid credit card at all times.
This credit card authorization form is kept on file for billing purposes and is used only in the event that an outstanding bill is not paid after sufficient notice that it is due. As stated in the client agreement, all fees, deductibles, co-pays and co-insurance are due by check or cash at the time of service.