Credit Card Authorization Form

Payment

• All payment is due at your session. Patients may not carry a balance.
• You may pay for sessions by debit card or credit card.
• Teletherapy sessions are pre-billed to a credit or debit card on file.
• If you were referred by Alma, this card will be kept on file to charge you for any missed session or late cancellation fees. Alma will process all other charges.

By filling out the information below, you acknowledge that any outstanding balances will be automatically charged to your credit card.

Credit Card Information

Use of Credit Card Information by Dr. Ronit Levy:

• By signing this form, you agree to pay all applicable fees associated with using your insurance such as co-pays, co-insurance, rejected claims or any other type of outstanding balance.
• By signing this form, you agree to pay all fees charged by Dr. Ronit Levy if you are paying out of pocket or for services not covered by insurance.
• By signing this form, you agree to provide Dr. Ronit Levy with a credit card number that will be kept on file and charged if you do not pay your balance.
• Out-of-pocket fees are due at each session. Teletherapy patients can pay their fees using a debit or credit card.
• You are responsible for all fees that are not paid by your insurance company such as coinsurance or any rejected claims. Balances must be paid immediately, or your card will be charged for the amount you owe.
• Phone sessions are charged the day they take place.
• Late cancellations are charged the day they occur.
• For your convenience, we can charge your balance to your card on file after each session.
• For privacy reasons, we cannot discuss anything related to a patient over the age of 14 (e.g., charges, attendance, cancellations, sessions, treatment) even though we are charging your card. The patient must sign consent first.