I hereby give consent to charge my credit-card/HSA/other card information or bill me directly for any outstanding balance and/or to process private pay amounts, missed or late cancelled appointment fees, as well as session deductibles, co-payments, co- insurance or any other amounts your insurance carrier determines as payable by you. I consent to allow Clearwater Counseling to store and process my credit-card/HSA/other card information provided below through Square.
If my Health Insurance carrier has not paid a claim within 60 days of the date of submission, I accept responsibility for payment in full of any outstanding balance and authorize Clearwater Counseling to apply these charges to the credit-card/HSA/other card information on file or bill me directly for the full amount. I may then collect directly from my health insurance carrier.
If I have ANY form of Private Pay outstanding balance beyond 30 days, where a payment plan has not been placed in effect, I accept responsibility for payment in full, and authorize Clearwater Counseling to apply these charges to credit-card/HSA/other card on file; if those do not process, I agree to be billed directly for the full amount.
I understand that should clinic fees or policies change, I will be notified in writing of said changes. I further understand that I retain the right to revoke this authorization, if done so in writing and faxed or mailed to the appropriate location (Woodbury Office: 1802 Wooddale Drive, Suite 101, Woodbury, MN 55125). I understand and agree to notify Clearwater Counseling in writing of any changes to my account information or termination of this authorization at least 15 days prior to the next billing date. Additionally I understand that visits will be suspended until a new payment arrangement is set up.