Thank you for choosing Great Strides Rehabilitation for your therapy services.  We are committed to ensuring that our billing processes are safe, convenient, and efficient for you.  It is our policy to collect deductibles, co-payments, and co-insurances at the time of your appointments.  Upon completion of this form, you are hereby authorizing Great Strides Rehabilitation to keep your payment method on file for future patient payments. A receipt for each payment can be provided to you as requested via email or physical copy. Any charges will appear on your credit card or statement.

 

If the amount due is a fixed copayment, I acknowledge that the Great Strides staff will automatically charge the payment form on file for the amount due for that session.

 

I agree to notify Great Strides Rehabilitation in writing of any changes in my account. This credit card/bank information will be kept on file and will remain in effect until the expiration of the account until payment is made in full. I acknowledge that the origination of Credit Card or Bank Account transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this Credit Card or Bank Account and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form.

 

Upon Great Strides Rehabilitation's receipt of notification from my primary or secondary [if applicable] insurance carrier that I am responsible for any applicable deductible/coinsurance/copayment, a statement will be sent to my contact information provided. If a response is not received within 15 days of receipt, I authorize Great Strides Rehabilitation to charge my payment form on file for any balances owed on serviced rendered.