CREDIT CARD AUTHORIZATION

Please complete this form in its entirety. All patients 18-year-old and older are required to provide a picture ID (school ID, military ID, etc.) for verification and to prevent insurance fraud. Please keep us informed of any changes related to your credit card information to prevent being in default under this agreement.

We accept

• I consent to electronic signature with credit card swiped. • There is a fee of $35.00 for returned checks. • Refunds cannot be processed once service has been provided.

Payment

• Payment is expected at the time of service.
• Patients are responsible for the payment of all services rendered by Wilmington Mental Health providers and affiliates.
• Any deductible, co-insurance and co-pay balances are the patient’s financial responsibility.
• We may charge an extra $5 for copayments not paid at the time of service.
• We reserve the right to reschedule, cancel, and/or terminate services due to payment noncompliance.
• Any “promise to pay” not satisfied by third-party vendor is ultimately the patient responsibility. Patients are responsible for collecting any reimbursement directly from the vendor.
• We ask patients not to discuss account balance or financial information with their provider or medical staff. 

Overdue and Credit Balances

• WMH will charge the credit/debit card on file for services not paid by the insurance company within 90 days from the day the service was rendered, including copays, deductibles and/or coinsurance.
• Payment arrangement may be offered if the patient is able to demonstrate financial hardship.
• Any current/future appointments may be cancelled until full payment is received.

Refunds

• Any refund or credit issued to a credit card could take between 3-5 days to be credited back on the account.
• In some cases, we may send a check by mail when processing account credits or refunds that fall outside of the timeframe allowed by our credit card processor to complete these transactions.

Attestation

• You signature below indicates that you understand your responsibility regarding payment for all services associated with your treatment, including copayments, coinsurance, and annual deductibles.
• Your signature confirms that all information provided on this form is accurate and gives Wilmington Mental Health permission to charge your credit card, bill your insurance company, and request payment for your treatment from thirdparty companies other than your insurance provider.
• Wilmington Mental Health and/or any of its associates will charge your credit card for any covered service, no-show/late cancellation fees, and any balance that is more than 30 days overdue.

If you decide to revoke this privilege and your account is paid up in full, you may withdraw this authorization at any time and communicate this request by contacting Wilmington Mental Health at 910-777-5575 or by email at info@wmhwc.com