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

DetoxResidential

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.*

AgreeDisagree

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.*

AgreeDisagree

Date*

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I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates.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