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Financial Services Agreement

Skypiatrist Psychiatry requires you to provide your credit/debit card information on file with us so we can automatically charge any co-pays, co-insurance, deductible amounts, and other professional service charges such as late cancellation or missed appointment charges. It is the client’s responsibility to keep cards accurate and up to date. We store financial information and other protected health information in an encrypted, HIPAA compliant site.

Payment is required at the time of service, or when we are notified of a balance by the insurance company. If balance accrues and no payment is received, we reserve the right to seek payment by any means, including using the credit/debit information we have on file, retaining a collection agency, and/or taking legal action in court. If we must seek payment by collection, then there will necessarily be disclosure of certain limited but otherwise confidential information about you and your treatment with us; your name, address, phone number, dates of service, type of service rendered and the amount due. We may be willing to work out a client payment plan that includes a reasonable period for resolving the balance. If the client’s balance remains unpaid, then we reserve the right to initiate a termination of treatment procedure.

This authorization will remain in effect until the expiration date of the card or a written request to revoke the authorization is received by us at