I, {cardholderName}, as a cardholder, hereby authorize Dove Psychiatry PLLC, to charge my credit card for {conditiontext} and confirm that the information for the credit card and billing address is complete and accurate.
I have been informed that I can cancel the recurring payment at least 15 days before the payment by phone or signing a consent form provided by the merchant company.
Credit Card On File Policy:
Dove Psychiatry-NP, PLLC is dedicated to making our billing process as easy as possible, for you and for our staff. When scheduling your first appointment, it is required to leave a credit or debit card on file to cover fees related to copayments, and any outstanding balances for services rendered, such as, deductibles, co-insurance, same day cancelation fee, no show fee, any medical documentation, or if you are on a private payment plan. We accept all credit cards, FSA, HSA, and debit cards.
The card that you save on file will be charged on the day of your appointment, we do not accept cash or checks. Failure to pay your balance within 7 days, will constitute your balance being sent to collections and termination from the practice. Please be cognizant if your card becomes expired, or if there is an error with your card, it is your responsibility to provide a new form of payment.
Out Of Pocket Costs & Rates:
Please contact the office either call or text to inquire.
No-Show and Same-Day Cancellation Policy:
We understand that situations can arise unexpectedly. However, due to the high demand for appointments and to ensure we can accommodate all our clients effectively, we have implemented the following policy regarding missed or canceled appointments:
Cancellation Notice: We require a minimum of 48 hours’ notice to cancel or reschedule an appointment. This advance notice allows us to offer your appointment slot to other clients who may be waiting.
Fees for Late Cancellations and No-Shows:
Intake Appointments: $100
Follow-Up Appointments: $70
These fees are necessary to cover the cost of reserved time and to help manage our schedule efficiently. We appreciate your understanding and cooperation.
To cancel or reschedule an appointment, please contact us as soon as possible. If you have any questions regarding this policy, feel free to reach out to our office.
Thank you for your consideration and for helping us serve all our clients better.