Credit Card Authorization
I hereby authorize Mental Health Specialty Group, P.A. (“MHSG”), or its administrative agent, PathCCM, Inc., to process the credit card as “Card on File” and I understand that this authorization will remain in effect until the expiration of the credit card account for any costs associated with the services described in this Financial Responsibility Agreement. However, I understand that I may revoke this authorization at any time by submitting a written request to MHSG.
I understand that it is the policy of MHSG that I maintain an active credit card on file with MHSG prior to receiving any treatment services.
I, THE UNDERSIGNED HAVE READ AND UNDERSTAND THIS FINANCIAL RESPONSIBILITY AGREEMENT. I HEREBY ACCEPT FULL RESPONSIBILITY FOR PAYMENT OF ANY FEE(S) NOT COVERED BY INSURANCE OR ANY FEES ASSOCIATED WITH SELF-PAYMENT OF SERVICES.
Have questions? Email firstname.lastname@example.org