Financial Agreement

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Patient Financial Agreement

1. PAYMENT is expected prior to each appointment and with each month. Monthly costs are for memberships and help support MAO Inhibitors, Inc but may not constitute payment for specific billable services. We accept most major credit cards through PayPal services.
2. INSURANCE AND INSURANCE PLANS: We are not processing health insurance at this time.
3. RESPONSIBILITY FOR PAYMENT: You are financially responsible to for all charges relating to your care.
4. STOPPING MEMBERSHIPS: You may cancel your membership at any time by emailing us at [email protected] and requesting your membership be canceled. The membership fee is automatically processed monthly. To cancel your membership without incurring the following month’s membership fee, you must notify us of your desire to cancel at least 48 hours prior your renewal membership fee is due.
5. RELEASE OF INFORMATION: You authorize and direct MAO Inhibitors, Inc to release (verbally or in writing) confidential medical information to any person, entity, government agencies, insurance carriers, or others who are financially liable to MAO Inhibitors, Inc for charges for medical treatment, and for quality management, utilization review, transfer of medical care, and follow up purposes.
8. BILLING, COLLECTION, AND CREDIT CARD AUTHORIZATION: You authorize MAO Inhibitors, Inc to store and charge my credit card or other payment method automatically as well as for any missed payments or outstanding balance. MAO Inhibitors, Inc reserves the right to be reimbursed for any collection costs or other costs incurred by attempting to collect payment from me.
9. REFUND & CANCELATION/NO SHOW POLICY: All payments are non-refundable. If you cancel an appointment, you can reschedule straight from your account or you can always contact us. If it is more than 24 hours until your appointment, we will provide you with a voucher worth the amount you paid to use towards your next appointment. If you contact us to reschedule within 24 hours of your appointment, we will provide you with a voucher worth the amount you paid minus $30 as a late cancelation fee. Vouchers are non-transferable and expire one year after the original scheduled appointment date. They are only applicable towards appointments, for single use only and cannot be split between appointments nor combined with other vouchers or discounts.