HVCC Client Financial Responsibility

Payment for any clinical services received at HVCC is due prior to time of service, including but not limited to any co-payment, deductible fees, or Self-Payment fees due based on current insurance held by client, or lack of insurance. Clients are required to update HVCC if they are made aware of any insurance changes. Payments will be accepted in the form of cash, check, or debit/credit card.

Telemed Services:

If you plan to, or currently engage in Telemed services HVCC requires a Credit Card on file to charge for services on date of service rendered if no manual payment by client is made.

If payment method below fails, client will be contacted and given 10 days from appointment or by next appointment (whichever is soonest) to make payment using an alternative method or payment arrangement should be made with HVCC Billing. If no payment or payment arrangement is made, client will be at risk of suspension or discharge from services.

Name

First Name

Last Name

Date of Birth

YYYY

For receipts

Authorization

I hereby authorize Hockanum Valley Community Council to charge the applicable appointment fee to the credit card listed below immediately following any Telemedicine clinical session with HVCC staff.

Name on Card

First Name

Last Name

Card Number #

CVC #

Exp. Date

Zip Code

Virtual Signature

By typing my name below, I agree to the terms and conditions of the HVCC Client Financial Responsibility form.