I understand that full payment is required at time of service and that any deductible, coinsurance, or copayment amounts related to my insurance coverage is my financial responsibility.

I understand that I must provide a valid credit card to be kept on file through the duration of my treatment services.

I agree to keep an active credit card on file and authorize the use of this credit card for payment of co-insurance, deductible, co-pays, or any other self-pay client responsibility related to services rendered.

I agree to call and notify the receptionist if my credit card expires and will provide a updated credit card prior to my next service.

I understand that I will not be admitted to treatment if credit card authorization has not been completed prior to my initial appointment or evaluation.

I understand that I am responsible for providing accurate information regarding active insurance coverage. I understand that it is not the responsibility of JADE Wellness Center to monitor the status of insurance coverage. Furthermore, I have been advised that it is my responsibility to inform JADE Wellness Center of any changes in insurance status.

I understand that I am responsible for any balance accrued due to insurance termination, insurance changes, or insurance denials.

I understand if I accrue a balance for any reason that I will be alerted of the outstanding amounts and will be given fourteen days to resolve said balance. If no other arrangements are made within fourteen days, the credit card on file will be charged for the full balance due. In the event the credit card charge cannot be completed, treatment services will be paused until the outstanding balance is resolved.

I have been made aware that payment plans are available to assist clients in resolving outstanding balances. All payment plans must include full balance resolution within 180-days. Payment plans must be signed prior to continuation of service.

A $25 fee will to be assessed for each failed payment plan transaction.

Should any balance be open on your account at time of discharge or discontinued treatment the remaining balance shall be run in full.

The undersigned authorizes JADE Wellness Center to charge account balances to the above credit card for services rendered at JADE Wellness Center. I acknowledge and agree to comply with the terms outlined in this payment policy.

By signing below, I acknowledge and consent to the use of your credit card without signature on the charge slip, that this agreement will serve as an original and this credit card authorization