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 &/or Stripe to process your transactions. I verify that my payment method information, provided above, is accurate and to the best of my knowledge. 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. You are responsible to pay your fees on time to avoid any interruptions of services.
I also understand that by 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.
Attention Payor/cardholder: By signing and adding your card information you are authorizing future payments of service for the client, and agree to notify regarding updates to credit cards, and accounts.
