Fees are payable at the time that services are rendered. Please ask your therapist if you wish to discuss a written agreement that specifies an alternative payment procedure. Your payments will be on auto payments.
I authorize My Serenity Mental Wellness to charge my credit/debit account card for professional services. MSMW uses IVY Pay to process your transactions. I verify that my payment method information, provided above, is accurate and to the best of my knowledge. The card on file can be used to pay for treatment services including copays and deductibles/no shows/late cancellations etc. If this information is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed and additional costs incurred if denied. If payment is rejected there is a fee of $10 for the rejection of a direct deposit and $35 for bounced checks. You are responsible to pay your fees on time in an effort to avoid any interruptions of services.
I also understand that by signing and initialing this form, that if no payment has been made by me, my balance will go to collections if another alternative payment is not made within thirty days. Your credit card information will be stored in a HIPAA compliant electronic health system.
*Note you may be asked to add a secondary card to file if your first payment declines.