Virtual Patient Financial Agreement

Please correct the errors described below.
(Example: 5/30/2010)

You have registered as a virtual patient with Advanced Behavioral Health Center. This means costs associated with your co-insurance, co-pays, and deductibles will be collected one business day prior to your scheduled appointment to ensure payment is received for services rendered.

To expedite the payment process, please read through our Credit Card Authorization and complete the form.

Advanced Behavioral Health Center, Credit Card Authorization for Virtual Appointments

I, the undersigned, authorize Advanced Behavioral Health Center to charge my card on file for the amounts owed by me to include co-pays, deductibles, and "no show" fees. (Please note: This does not include past-due balances.) I understand that I will be sent receipts for credit card charges via email and that such charges will appear on my credit card statement. I understand that a credit card is required to be on file prior to telehealth services being rendered. I understand that this Credit Card Authorization will remain in effect until I provide written notice of cancellation to Advanced Behavioral Health Center.

All Virtual/Telehealth patients must have a debit/credit card on file and consent to our Credit Card Authorization. Please call 352-742-8300 to schedule an in-person appointment.

(enter the last day of the month in which the card expires)
(Example: 5/30/2010)

Your information will be encrypted.