Financial Responsibility & Credit Card Authorization Agreement

Michele D. Shieldes, PLLC / Innovative Therapy Group

Financial Responsibility

I understand and agree that I am financially responsible for payment of all services rendered, regardless of insurance coverage, benefit determinations, or pending claims. Verification of insurance benefits is not a guarantee of payment. I am responsible for all copayments, coinsurance, deductibles, and non-covered services. If insurance denies or reduces payment for any reason, I remain responsible for the balance. Payment is due within 15 days of billing. If the Practice is out-of-network, full payment is due at the time of service.

Accounts not paid within 30 days may be subject to suspension of services, late fees as permitted by Texas law, referral to collections, and recovery of reasonable attorney’s fees and costs. Returned or declined payments may result in additional processing fees.

Responsible Party Signature (Financial Responsibility)

Credit Card Authorization / Card on File

I authorize the Practice to maintain my credit or debit card on file and charge amounts due, including copayments, coinsurance, deductibles, private pay services, and unpaid balances after insurance processing. Charges will be processed only after services are rendered. Notice of charges will be provided upon request.

Card information is stored securely in accordance with applicable payment processing standards. I agree to maintain current card information and promptly update changes.

A  3% convenience fee applies to credit card payments as permitted by law. No convenience fee applies to debit card, cash, or check payments.

Card Information (For Secure Processing)