Permission to Collect Payment

I understand that any applicable deductibles, copays, and coinsurance amounts will be charged to my credit card shortly after each session, based on information provided by my insurance carrier. If I wish to be notified in advance of these charges, I will contact the SpringSource Psychological Center, PLLC billing department at the beginning of treatment to make arrangements.

Additionally, I authorize SpringSource Psychological Center, PLLC to charge my credit card for services and/or for any balance due that has not been paid 30 days after it is received.

I understand that if I miss the appointment or do not cancel 24-hours prior to the appointment, SpringSource Psychological Center, PLLC is authorized to charge my credit card the same amount as the missed appointment.

If at any point I wish to receive a statement of any and/or all charges, I may contact the SpringSource billing department and make such arrangements.

I have read and understand this form. I attest that the information provided is true and accurate.