Authorization for Payment Card Auto-Pay

I authorize Spencer Psychology to store my payment card information on file with Spencer Psychology's third-party payment processing service for automatic payments. I also authorize Spencer Psychology to charge outstanding balances on my/my authorized user’s account for services, no shows and late cancelations. I agree that no prior notification is required for charges on my card and that this authorization remains in effect until I notify Spencer Psychology in writing or email to admin@spencerpsychology.com.

I understand that:

• Payment is due at the time of service and that I will need to keep a valid credit card on file to be charged after each session.
• A receipt for each payment will be provided, and the charge will appear on my payment card statement.
• Card numbers are not visible to Spencer Psychology staff.
• No shows/cancelation fees are not eligible for payment by a Health Savings Plan (HSA), but if a HSA is used for these fees, the card holder may have to reimburse the HSA account if audited. Spencer Psychology will not know if a card is for an HSA account, and are not liable for clients not following HSA plan requirements, or for clients not following guidance given by the card holder.
• Due to privacy regulations, Spencer Psychology may not discuss with the card holder any clinical information for the adult client, nor arrangements made with the client about choice of session type, no show/late cancelation fees, or waivers of insurance. These issues will be explained to the client, and it is the client’s responsibility to discuss this with the card holder.
• If I allow another person to use this payment card for services and fees, I am responsible for the charges the client incurs. I understand it is my responsibility to monitor this use with the client and with my payment card statement, and that Spencer Psychology cannot refund legitimate charges to the card that the authorized user/client uses.
• If my card declines and multiple attempts are required to charge the balance for the same session, there may be a processing fee.
• If the cardholder initiates a credit card charge-back for services already performed and charged in good faith, I, or the responsible party, am still liable for the balance on the account. If you/responsible party/cardholder believe you have been charged in error and are due a refund, please contact the office directly so we can help you.
• If I discontinue services at any point, my payment card will be charged for any remaining balances owed.
• Refunds cannot be made retroactively from the receipt of the written notice of cancelation.
• If you have Medicaid/HIP insurance, we need a card on file in the event you had appointments after your Medicaid coverage ended.

I have read and agree to all of the above
Please check the box to confirm that you have read this policy and understand Enter last four digits of card
 
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This card is:

Primary (replace any other cards on file)

Secondary (keep primary card on file)

Other (We will contact you)