I authorize Raleigh Wellness Behavioral Health to charge this credit card for copayments, deductibles, coinsurance, no-show fees, and any balances on the account of the patient named below. These charges will be for services rendered by clinicians at Raleigh Wellness Behavioral Health.
I understand that visit fees will be charged each morning prior to the appointment unless other arrangements have been made and agreed upon by both the patient and Raleigh Wellness Behavioral Health. For my new patient appointment, my credit card will be charged for the applicable copay, deductible, or coinsurance one business day prior to the appointment.
I understand that it is my responsibility to know what portion of these services I, as the patient, am responsible for.
I understand that my information will be saved on file for future transactions on my account.
