Private Pay Agreement

Please correct the errors described below.
Example 05/30/2010
Virtual appointments can be video or telephone appointments

You are registering as a private-pay patient with Advanced Behavioral Health Center. This means that at the time of service, you will be paying by cash or debit/credit card. Advanced Behavioral Health Center will make no attempt to bill your insurance provider for services provided under this private-pay agreement.

*Please initial each item below to indicate that you have read, understand, and agree to the following*

To complete your registration as a private pay patient, please carefully read the following Credit Card Authorization.

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.

*Please note: All virtual/telehealth patients must keep a card on file with ABHC and agree to pay for services one business day prior to their appointment.

Self-Pay Rates:

Physician Appointments, New Patient Evaluation: $400.00

Physician, Follow-Up Appointments: $200.00

Therapy Sessions, New Patient: $175.00

Therapy, Follow-Up: $140.00

(Typically, 3 digits on back of card)

This version created on March, 2, 2023 by CMcD

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