DP Clone of AIBH AISWC- All In Solutions Wellness Center

Lead ID

Email

example@example.com

Client Name (First Name)

Ex. Jane

Client Last Name Initial

Initial of Last Name

Payment Method

The following constitutes the financial policy of All In Solutions Wellness Center LLC, hereafter called “facility”, regarding services rendered at the facility.

Please sign and complete this form to authorize All In Solutions Wellness Center LLC to charge your card/account for the amount listed below. You hereby authorize All In Solutions Wellness Center LLC permission to charge your credit card for the non-refundable medical/psychological services by signing this form.

In addition, by signing this form, you attest that the credit card and billing address information is complete and accurate.

Initials

A. Facility Charges

For the following services: Initial Assessment, Psychiatric Evaluation (if needed), Treatment Services, Ancillary Services

B. Collecting towards levels of care indicated and agreed upon below:

C. Payment Date 1

On this date, Payment 1 amount will be processed

D. Payment 1 Amount

Secondary payment is only required if Payment 1 is not equal to the total cost of facility charges

E. Payment Date 2

On this date, Payment 2 will be processed

F. Payment 2 Amount

G. Total Cost

Client Full Name

First NameLast Name

Payor Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

As the payor, I agree to the terms and conditions within this agreement, and by signing this form, I authorize my payment method to be charged on behalf of the patient listed.

1. Facility charges for the following services:-Initial Assessment-Psychiatric Evaluation (If Needed)-Ancillary Services

2. Client/Payor is responsible for all charges incurred.

3. All payments are due in full upon receipt of statement.

4. Initial payment for treatment services is due prior to admission unless insurance assignments are accepted. Subsequent payments are due on the first day of each subsequent treatment period.

5. If cancellation occurs prior to admission to the facility, there will be a 15% non-refundable fee incurred by the cancelling party. Therefore, 85% will be refunded to the payor.

6. If for any reason, the client decides to leave prior to the end of treatment, all money collected will be considered non-refundable.

7. I have provided All In Solutions Wellness Center LLC with accurate financial information and have participated with the planning of this financial agreement. I understand client is responsible for all fees and financial obligations.

8. I understand that my records are protected under Federal Confidentiality Regulations (42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal Laws and 42 CFR Part 2 for Federal Regulations) published August 10, 1997 and cannot be disclosed without written consent unless otherwise provided in the regulations. I understand that my medical records may contain information concerning my psychiatric, psychological, substance abuse, HIV/AIDS and or related conditions.

Date

Signature

I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that All In Solutions Wellness Center LLC may at its discretion attempt to process the charge again within 30 days, and agree to an additional $35.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions or credit card transactions applied to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute this transaction with my bank or credit card company; so long as the transaction corresponds to the terms indicated in this authorization form.

All In Solutions Contact Email

example@example.com

Financial Agreement