Payment Form For Patient Spending Money, Fees, or Miscellaneous

Payment Form For Patient Spending Money, Fees, or Miscellaneous

Book Money = Members personal spending account
Welcome, Granite Mountain Family!

This form serves primarily for depositing funds into your loved one's account designated for "book money," which is also referred to as personal spending money. Additionally, it can be used for miscellaneous fees (excluding OP Sober Living Fees) or payments related to Summit Behavioral Health of AZ, operating as Granite Mountain Behavioral Healthcare. It's important to understand that your loved one will not have unrestricted access to this money. We've implemented an accountability system wherein all funds are securely managed by our department staff and meticulously tracked by our bookkeepers for accurate record-keeping.

Due Date: To Ensure your loved one receives the "book money" in time for the upcoming weekend, all transactions need to be submitted by Thursday morning by noon. Requests for Book Money beyond this time will be processed for distribution the following weekend.

For our Alumni members; Please do not use this form for OP Sober Living Fee's! (As of 4/1/23)
Payment Details:

Red asterisks are required
1. Dollar amount for this Transaction*

prevnext( X )
USDPlease "type in" the amount of money you are putting on a members account
2. What is the Payment For? (required)

Patient Book Money (Personal Spending Money)Fee for treatment or other expense, (use other form for OP sober living Fee)Medication cost for reimbursementOther
Additional Explanation of Payment- What is the money for (If Needed)?
Optional
Who is sending/receiving the Money:

Red asterisks are required
3. Payee: (Name of the person putting money through this form)*

First NameLast Name
Payee Relationship to the Member (Optional)

ParentSiblingSignificant OtherFriendExtended FamilyOther
4. Patient/Member Name: (Money is for Whom?)*

First NameLast Name
Demographic Info:

Red asterisks are required
5. Payee E-mail*
example@example.com
6. Payee Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Any additional Details: (if needed)
Additional Information:

Important note and uses for spending money to there location
Please Note:

Granite Mountain Behavioral Healthcare parent company is Summit Behavioral Health of AZ Company. As a result, the receipt/email you receive will display the Summit Behavioral Health of AZ company name.

If you encounter any complications with this transaction or form, please don't hesitate to reach out to the form moderator, Ben Isenberg, at 928-710-7021.

Should a refund become necessary, you'll also need to coordinate with Ben. It's important to note that the refund process might take 72 hours or more to complete, returning the funds to the originating bank account.

Member uses for personal Spending money and Locations:

Phase I Residents (Prescott): If your loved one is currently a resident of our Willow Lake Road facilty during Phase I of residential treatment, they will have weekend access to our convenient store. This store offers a selection of comfort items including snacks, sodas, beverages, candies, and tobacco products. It's important to note that contributing funds to your loved one's account is purely optional; it's not a requirement for fulfilling their nutritional needs. This practice is regarded as a privilege and an additional comfort. The amount you choose to contribute is at your discretion, with reason in mind. Generally, we advise against sending more than $100 per week. Please don't hesitate to reach out if you have any inquiries or concerns.

Phase II Transitional (IOP) Program Residents (Prescott Valley): Residents in this phase have the opportunity to visit various stores and grocery outlets to fulfill their weekly living needs. At times, additional financial support from family or friends can be beneficial in meeting these needs. However, please understand that contributing extra financial support is optional and viewed as a privilege. It's important to strike a balance between aiding a member's needs and potentially enabling them through the amount you choose to provide.
Payment Method Details (required for payment):

Please select "Debit or Credit Card" or "PayPal"

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Payment Form For Patient Spending Money, Fees, or Miscellaneous

Payment Details:

Who is sending/receiving the Money:

Demographic Info:

Additional Information:

Payment Method Details (required for payment):