Credit/Debit Card Policy and Payment Agreement
For clients with HSA cards please call 805-679-3034 and leave that information on our secure voicemail. Include the name, expiration date, security code, full address, and card number for your HSA card. Due to the erratic nature of HSA funding we require a back-up card in case we are declined payment. Please fill this form for your back-up card.
I agree to have my credit/debit card charged for any balance which is PAST DUE for services provided by the office of Santa Barbara Integrative Psychiatry. [please initial]
I agree to have my credit/debit card charged for the full appointment fee for times when I no show or cancel less than 48-hours before the time of the appointment (no show/late cancellation). [please initial]
I understand that by initialing below, I am not waiving my rights under my credit/debit card company to dispute any charges applied to my credit/debit card. [please initial]
I understand that the office of Santa Barbara Integrative Psychiatry is HIPAA compliant and that all information provided is protected by encryption and other information protection policies that meet or exceed the statutes set forth by HIPAA. I also recognize that no information is 100% protected from breaches and I accept the risk of possible breaches to my information that was kept at or above the HIPAA standard. [please initial]
Note: You may be able to get reimbursed for some of the cost of your appointments if your health insurance has out-of-network mental health benefits. The following 2 statements are to be initialed only by those of you who have out-of-network mental health benefits. Otherwise put NO in the answer box.
I have checked my health insurance and I currently have out-of-network mental health benefits. [please initial]
I want to receive a superbill after each appointment sent to me via email or fax and accept any risks of possible information breaches that may occur if my email system is breached. [please initial - if you want the superbills faxed only please enter the words fax only after your initials]
Please enter your LAST name:
Please enter the name that appears on your credit/debit card
Please enter the expiration date:
Please enter the security code:
What type of card are you providing us with:
Please enter your card number:
Please enter the zip code linked to your card
I understand that providing my initials below indicates my acceptance to allow Santa Barbara Integrative Psychiatry to charge my card and store its information on the encrypted servers maintained by Square, Inc. [please initial]
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