CREDIT CARD AGREEMENT

At Greater Heights, Holistic Psychiatry, patients, or the responsible party are required to keep a Credit or Debit card on file as the method of payment for all services rendered. The Credit or Debit card must be on file prior to the patient's first appointment.

We will charge your credit card on file for the following:

1. Your appointment visit fee/copay/deductible fee on the morning of your appointment day.
2. Late cancellation/late-show/late-reschedule and/or no-show fees – these will be charged on the day of missed appointment.
3. Fees for any telephone consultations, telemedicine, or in-person visits/procedures.
4. Any additional services including writing letters/forms etc.
5. Any outstanding balances. – These charges are processed on an ongoing basis and/or next billing cycle.

Your credit card information is kept in a PCI-compliant system.

Debit/Credit card Information:

 
Account Type
AMEX
Visa
Master Card
Discover or Other

Billing Address:
 

By signing below , I authorize Greater Height Holistic Psychiatry PLLC to keep my signature and my credit card information securely on-file in my account. I authorize Greater Heights Holistic Psychiatry PLLC to charge my credit card for any agreed upon payments. I have reviewed the updated financial policy of Greater Heights Holistic Psychiatry PLLC. If the credit card that I give today changes, expires, or is denied for any reason, I agree to immediately give Greater Heights Holistic Psychiatry PLLC a new, valid credit card which I will allow them to charge over the telephone. Even though Greater Heights Holistic Psychiatry  PLLC is not processing the new card in person, I agree that the new card may be used with the same authorization as the original card I presented.