• Card on File Agreement

    Please use this form to put a card on file so that we can simplify the process of paying your copayment and session balances. You will not add any credit card information on this form. You can set up a payment method during your automated checkin, in office, or by contacting our office at 978-296-5595.
  •  - -
    Pick a Date
  • Card on File Agreement

    Card on File Agreement

  • I agree to allow Integrated Behavioral Care LLC / Integrated Behavioral Care New England LLC (the “Practice”) to charge my credit card (the “Payment Method”) for any patient balance due (up to the Maximum Charge Amount of $1,500), for all services provided by the Practice on or after the Effective Date verbally discussed and before the Expiration Date (1 year from today). I acknowledge that: 

    • My Payment Method will only be charged for the remaining patient responsibility not paid by insurance, after applicable insurance has been applied. 
    • I will receive a receipt for each payment detailing the amount charged. 
      My Payment Method will be charged for services rendered to the Patient (listed above) and any patient(s) who, at the time their charge drops, have combined billing and statements with the above patient (if this functionality has been enabled with the practice). 
    • If the eligible charge(s) exceed the Maximum Charge Amount, the Practice will bill me directly for any remaining amount beyond the Maximum Charge Amount, and I will be responsible for any such balance. 
    • My Payment Method information will be securely stored by the Practice and/or the Practice’s trusted service providers to facilitate collection of payments. 
      I may cancel this Authorization at any time by contacting the Practice. If I cancel, the Practice will bill me directly for any patient responsibility, and I will be responsible for any such amounts. 
    • If I make any changes to this Card on File Authorization (e.g., by contacting the Practice or via online payment workflows powered by athenahealth, Inc.), such changes will supersede the details included in this Authorization and will automatically amend it. 
    • All information I have provided in connection with this Authorization is true and accurate. I certify that I am an authorized user of the Payment Method. 
      By checking this box and signing below, you are entering into a legally-binding contract with, and providing consent to, your (or the patient’s) health care provider for the provision of services, treatment, or other matter(s) described in this Consent Form. 
  • Clear
  • Client Signature

    Client Signature

    I certify that I have reviewed and agree to the terms for the: Consent for Services, Practice Policies, Electronic Communication Consent, Insurance Policies, and Telehealth Informed Consent.
  • Should be Empty: