Credit Card Policy Authorization

In recent years there have been significant changes to insurance policies (higher deductibles, copays, and coinsurance) which place a portion of the financial responsibility for your health care on you as a patient. As a courtesy to patients, Health Psych Maine staff will check insurance coverage and obtain an estimate of patient financial responsibility, but the final cost to you is dictated by your insurance company’s Explanation of Benefits for each visit, and it may be higher or lower than the estimate.

Health Psych Maine requires that a credit or debit card for each patient be stored securely on file with our practice management system, TherapyNotes. The card will be used for future payment for some of the following reasons:

1. You opt to pay the estimated patient financial responsibility due on the day of service with your card on file.

2. You have canceled with less than 24 hours’ notice or did not show up to a scheduled appointment, resulting in a $50 fee.

3. The Explanation of Benefits from your insurance company indicates additional patient financial responsibility because of the following:

  • Deductible has not been met for the current calendar year
  • Coinsurance may be applied to the charges
  • Service may be deemed as a non-covered benefit under your plan policy
  • Policy has terminated and you do not inform us of your new insurance provider, or there is a gap in coverage
  • A copayment for medical services rendered is due

4. You have set up a payment plan for larger balances on the account

5. You have an outstanding balance due on your account


By signing below, I authorize Health Psych Maine to keep a credit card on file for future payments and to charge all balances accrued on the account to the card information saved with TherapyNotes. I further understand that if a payment is denied by the credit card on file, the balance due must be paid in full before future appointments at Health Psych Maine may be made. The account may be sent to an outside collections company if the account becomes more than 90 days past due. I understand that I am responsible for notifying Health Psych Maine of any changes in my contact information or health insurance information that may affect the payment process.

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