The purpose of this form is to authorize Central Texas Therapy Spot, PLLC to retain a valid payment collection method on file for you as our patient. This form will be kept confidential along with the payment method you provide.
I UNDERSTAND Central Texas Therapy Spot, PLLC WILL CHARGE MY CARD FOR THE FOLLOWING.
1. Co-Pay, Co-Insurance, & Deductible amounts as determined and provided by the patients insurance company.
2. Self pay services
3. Outstanding balances- If you, as the guardian of the patient or the patient, have an outstanding balance greater than 60 days with the clinic, we will charge an agreed amount until the balance is paid off.
4. No-Show Appointments- Missing a scheduled appointment without proper notice to cancel or reschedule, Central Texas Therapy Spot, PLLC reserves the right to charge the payment method $50.00 for our standard no-show fee and a reciept will be sent to the current address on file.
A valid payment method will need to be provided at the time of service. If patient is not being seen at the clinic, please contact the clinic to provide this information prior to the initial evaluation. We accept the following payment methods: Credit Card (Visa, Mastercard, Discover), HSA Cards, FSA Cards, Cash, and Check.
Other than the conditions mentioned above, under NO circumstance will Central Texas Therapy Spot, PLLC share your payment collection method. In conjunction with HIPPA regulations, all payment information will be confidentially kept within the patients medical chart.
Having read this form and talked with the staff, my signature below acknowledges that I give my authorization and consent providing the requested information for my payment agreement to be charged accordingly for the conditions stated above.